Your Information Name * First Name Last Name Birth Date * Gender * Female Male Height * Weight * Phone * (###) ### #### Email * How did you hear about Peak Performance and Wellness? * What is your current occupation? * Does your occupation require extended periods of sitting? * Does your occupation require repetitive movements? (If YES, please explain.) * Does your occupation cause you mental stress? * Do you partake in any recreational physical activities (golf, skiing, etc.)? (If YES, please explain.) * Do you have any additional hobbies (reading, video games, etc.)? (If YES, please explain.) * Have you ever had any injuries or chronic pain? (If YES, please explain.) * Have you ever had any surgeries? (If YES, please explain.) * Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes? (If YES, please explain.) * Are you currently taking any medication? (If YES, please explain.) * Do you smoke? * Yes No What is your daily activity level? * 1 (Very low) 2 3 4 5 (High) Which days of the week do you train (or plan to train) * Monday Tuesday Wednesday Thursday Friday Saturday Sunday Which of the following statements fit in with your goals? * Improved health Improved endurance Increased strength Increased muscle mass Fat loss Other Other: Select all services you are interested in. * Personal Training Nutrition Coaching Workout Programs Please rate your readiness to make changes to achieve your goals. * 1 (Low) 2 3 4 5 (High) Thank you!