After you complete the survey, you will receive a special offer from Body Sculpting™. Please note, you will not be required to provide your name or other personal information. The pre-client survey only asks for general information about your fitness habits and interests. Information will be provided on classes and videos that may be appropriate based on your survey answers. Once you have completed the survey, you will receive a coupon for savings on your online purchase of our exercise classes and videos.

Is Body Sculpting right for you?

Age:	Weight: Height:
Do you need to lose more than 50 pounds?     Yes     No
Medical Conditions:
Do you currently exercise?		Yes No If Yes, How many years?
If yes, what types of exercise do you do?		Run Walk Aerobics Yoga/Tai Chi Swim Jazz Exercise Dance Strength Training Pilates Treadmill Stationary Bike Other:
If yes, how often do you exercise?		I do not 3 x week 1 x week 4 x week 2 x week 5 or more x week
Have you ever lifted weights?		Yes No
Check all of the strength training exercises that you are familiar with and are able to do:		Squats Lunges Dumbbell Row Triceps Extension Deadlifts Overhead Press Lateral Raise Upright Row
Are you able to perform squats and lunges, similar to deep knee bends?		Yes No
What is currently preventing you from exercising?		Time Schedule Fear Lack of motivation Cost Lack of childcare Too much weight to lose Other:
Would you consider your experience in strength training:		None Limited Took a class before Regularly exercise with weights Competitive bodybuilder Used a personal trainer
Of the following, what would you most like to change or improve about your physical and mental health?		Increase flexibility Posture Reduce anxiety Increase strength Increase strength in shoulders/neck Minimize Depression Relieve Stress Ward off/prevent osteoporosis Lose weight Gain weight
What body part(s) would you most like to change:		Legs Back Arms Buttocks Abs Back Chest
Do you own:		An exercise mat A stretch band or physical therapy band A set of dumbbells
To help us reach our customers better, please answer the following questions:
What radio station do you listen to?
How often do you call Time and Weather (216-931-1212)?
What is your favorite television show?
What local television news do you watch?
Do you have cable TV?
Do you own a satellite dish?
Do you own a DVD player?
What magazines do you subscribe to?
What is your occupation?
Where would you expect to see Body Sculpting™ advertising?
Please add any comments or advice you think would be helpful to us:
* If you would like to receive more information, including a coupon for a free trial class and notification of sales and specials, please complete the following information. Please note that we never share your personal information, including e-mail, with any third parties.
* Name:
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