Assessment -

Fill out the the online Fitness Lifestyle/Nutrition Assessment below and a representative will contact you.

Name *

First

Last

City *

State *

If you live outside the Metro Atlanta Area, please respond to all that apply *

Phone Number *

Best Time to Call *

Email *

Rate your daily activity level *

Sedentary Moderately active Active Very active or athletic

Are You Married? *

Yes No

Do you have children? *

What is your age? *

Height *

Current Weight *

Goal Weight *

Current Shirt/Blouse Size *

Desired Shirt/Blouse Size *

Current Pants Size *

Desired Pants Size *

Are you currently or in the past on a diet or meal plan? *

Yes No

If yes, when? What was the type of meal plan? What were your results? *

Are you currently on a fitness/health program? *

Yes No

If yes, state what type of program? How long has it been? Did you have a personal trainer? What were your results? *

Do you smoke cigarettes? *

Yes No

If yes, how many cigarettes do you smoke a day? *

Do you drink soda? *

Yes No

If yes, how many sodas a day? *

Do you Drink coffee? *

Yes No

If yes, how many cups a day? *

If so, please list *

Do you have any physical limitations? *

Yes No

If yes, describe limitation. Which body part is limited? *

Have you had any surgeries, in the last 5 years? *

Yes No

If yes, the procedure performed? When? Do you still have complications? *

Are you taking any medications or supplements; if so please list *

How soon would you like to start your program? *

Immediately 1 - 2 Weeks 1 - 2 Months Unsure

How often would you like to meet with a trainer? *

1 x weekly 2 x weekly 3 x weekly 4 x weekly

What is your budget? *

$700.00 - $1000.00 Monthly $500.00 - $700.00 Monthly $300.00 - $500.00 Monthly

How did you hear about this site? *

Internet Search Advertisement Friend Other, Please State