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Needs Assessment
FITQUEST is committed to upholding the confidentiality and security of your personal information. We respect your right to privacy and have instituted practices that will help ensure that your personal information is handled responsibly.
required field indicates a required field

First Namerequired field

Last Namerequired field

Genderrequired field

Male

Female

 Agerequired field

E-Mail Addressrequired field

Home Number: - required field
Office Number: - required field
Fax Number: -
Do you have any Injuries or Health Related problems?
Purpose/Goal of program?
Were you previously active? If yes what did you do? When and why did you stop?
What is your current activity level?
What are your activity preferences?
What do you personally perceive as being your weakness when looking at these parameters? Rate 1-5 for each one. (5 being very strong 1 being very weak)
Cardio:  5 4 3 2 1
Strength: 5 4 3 2 1
Flexibility: 5 4 3 2 1
Nutrition: 5 4 3 2 1
Agility: 5 4 3 2 1
How many days do you have to commit to this program per week?
required field
How much time per session do you have to commit to this program?
required field
Where will you be performing the exercises?(Home,Gym, etc)
When do you need to peak? (be date specific)*sports performance only!
How and who referred you to Fitquest?
What would be your requested day(s) of the week and time(s)that you would be available for an appointment?
Please feel free to add any additional information: