Please indicate your personal health and fitness-related goals:
Reduce Back Pain
Lower My Cholesterol
Please tell us more about your exercise pattern and goals:
What is your exercise history?:
What health improvements do you need?
What other health improvements do you want?
What are your activity preferences?
What barriers to success do you anticipate?
How will you know you are succeeding?
What is your motivation level?
What is your confidence level?
Please use the space below to record three concrete commitments that you are willing to make to you own health goals. For example you might commit "To arrive, ready for exercise, on Mondays, Wednesdays, and Fridays by 6:30pm". These should be challenging but also realistic and attainable commitments. When finished, please sign
this form to signify your personal commitment.