Todays Date:(mm/dd/yyyy) Name:
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?
High Medium Low
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:
Name:___________________________________________
Signature:______________________________________
Witness:______________________________
