Name *

First Name

Last Name

Phone *

(###)

###

####

Sex *

Female

Male

I prefer not to say

Do you smoke? *

Yes

No

Do you suffer from hip, shoulder or back pain? *

Yes

No

Have you ever had surgery? *

Yes

No

Do you eat out more than three times per week? *

Yes

No

Are you comfortable preparing healthy meals? *

Yes

No

Would you describe your job as mostly sedentary (long periods of sitting)? *

Yes

No

Do you currently work out? *

Yes

No

What fitness equipment, if any, do you currently have access to? *

Check all that apply. Note: Although useful to have, the equipment listed below is not required. In absence of any special fitness gear, we’ll take advantage of household items and use body weight exercises to keep up the intensity of each workout.

Dumbbells

Ankle weights

Resistance bands

Jump rope

Kettlebells

Yoga mat

Yoga ball

Any cardio machine

Foam roller

None of the above

At this point in time, how long do you plan to work with me? *

Less than 6 months

More than 6 months

What is your mindset toward your goal? *

Inspired

Insecure

Fearful

Confident

Motivated

Unmotivated

Reluctant

Excited

Curious

Skeptical

None of the above

Do you have a support system? *

Yes

No

It is recommended that I undergo a thorough medical evaluation prior to beginning any exercise program. I further understand that BodyByTy is not a medically supervised facility, and therefore, I exercise at my own risk. *

I accept

After you click submit, you won't be able to freely edit your worksheet. If you'd like to ammend anything please bring it up at our session. *

Got it √