One80 Degree Lifestyle Solutions

  LIFESTYLE  SOLUTIONS 

It only takes 1 step to turn your life around!

One80 Degree Health Questionnaire

Please complete the following questionnaire to assist our staff in personalising your total experience with One80 Degree Lifestyle Solutions.

Your name:
Address:
Email:
Home Phone:
Mobile:
Do you have any injuries? (past or present)
Yes     No
Joints
Muscles
Neck 		Back
Shoulders
Knees
Do you have any Health Concerns?
Yes     No
Asthma
Blood Pressure
Diabetes
Heart Condition 		Medication
Stress
Surgery (6-12months)
What Fitness Goals do you most want to achieve? (Choose 2-3 options)
Improve general health & well being
Look better in or out of clothes
Reduce weight / body fat
Reduce Medical conditions
Stress management 		Feel better and have increased energy levels
Tone up & increase flexibility
Improve posture & strengthen joints
Boost metabolism / increase muscle tone
Sports specific training
When do you want to achieve these goals by (month and year)?  
On a scale of 1-10, how serious are you about accomplishing your health & fitness goals? 
Does your partner / family support you to have a fitter and healthy lifestyle? Yes     No
What has stopped you from getting started or staying on a consistent exercise program in the past?
Are you participating in any physical exercise now?
Yes     No     Comments:
Is there any area of your body that you specifically want to work on?
Is there anything not previously mentioned that would prevent you from getting started on a regular exercise program today?

The information I have provided is only a guideline to the limitations of my ability to exercise. I will not hold One80 Degree Lifestyle Solutions liable in any way for any injuries that may occur while I am training.