First & Last Name
Address
City
State
Zip Code
Email Address
Daytime Phone
Evening Phone
Name of Friends/Family You Would Like To Get Fit With:
How much time will you be devoting to a healthier lifestyle per week?
2 visits per week
3 visits per week
4 visits per week
5 visits per week
6 visits per week
7 visits per week
Are you willing to forego the cost of a cup of coffee, soda or a candy bar on a daily basis to fund your healthier body?
Yes
No
Is your spouse supportive of your desire to improve your well being?
Yes
No
Would an improvement in your health affect your family?
Yes
No
If yes, how?
What was the last thing you have done for yourself?
What areas of your body would you like to focus on?
Waist
Hips
Thighs
Chest
Arms
Glutes
On a scale from 1 to 10 (10 being most important), please rate the following:
Safety
1
2
3
4
5
6
7
8
9
10
24 hr Access
1
2
3
4
5
6
7
8
9
10
Sunday Access
1
2
3
4
5
6
7
8
9
10
Tanning
1
2
3
4
5
6
7
8
9
10
New Equipment
1
2
3
4
5
6
7
8
9
10
Personal Trainer
1
2
3
4
5
6
7
8
9
10
Shower Facilities
1
2
3
4
5
6
7
8
9
10
© Anytime Fitness™ 2002-2003
