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Exercise Plan Questionnaire
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Name
*
First
Last
Date Of Birth DD/MM/YYYY
*
Email
*
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What's your top reason for wanting the exercise plan.
*
Lose Body Fat, Develop Muscle Tone, Rehabilitate an Injury, Sports Specific Training, Motivation, Improve Health
Do you have any specific fitness goals? If so please list below
Do you prefer Am or Pm workouts
*
AM
PM
No Preference
Are you a member at a gym or leisure centre?
*
Yes
No
Do you own any fitness equipment? i.e Yoga Mat, Weights, Exercise Step? Please list below
Do you participate in any of the following. Please tick any that apply
*
Walking
Running
Cycling
Swimming
Other
None of the Above
If 'Other' was selected please state below what you participate in
How would you describe your current fitness level
*
Perfect
Good
Average
Poor
Unfit
How would you describe your current mobility level
*
Perfect
Good
Average
Poor
Frail
Is there any particular exercises or activities you want to avoid or feel uncomfortable performing
Please list any health complications or injuries you have that need to be taken into consideration for your plan.
How many sessions a week do you wish to complete
*
How much time do you have to complete a session?
*
0-10Minutes
10-15Minutes
15-20Minutes
20-30Minutes
30 Minutes +
Would you feel comfortable sharing some data on your weight, BMI and heart rate before and after the plan.
*
Yes
No
With Some Discussion
Additionally would you feel comfortable with before and after photos? These will never be shared without your permission and won't need to include your face
*
Yes
No
With Some Discussion
Submit
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Last
Email
*
Phone Number
*
Message
*
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Confirm email for updates on offers, injury advise and news
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Let's chat!
Need more information? Send me an email or drop me a line. I don’t bite!
Charlotte@rehabontheroad.co.uk
07971448719
