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Health and Fitness Goals

This questionnaire will help us to understand your personal fitness goals. It is also a "contract" in which we ask you to make a commitment to three concrete steps towards fitness and health. It is not a legal contract with us but rather a personal contract that you make with yourself and with others concered with your health. Should you have any questions, feel free to ask. Your responses will be treated in a confidential manner.

Todays Date:(mm/dd/yyyy)

Please indicate your personal health and fitness-related goals:

Lose Weight
Improve Flexibility
Reduce Back Pain
Stop Smoking
Reduce Sress
Improve Diet
Fell Better
Lower My Cholesterol
Aerobic Fitness
General Fitness
Muscular Size
Muscular Strength
Sports Specific
Look Better
Injury Rehab

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.

Commitment #1:
Commitment #2:
Commitment #3: