YOUR EXERCISE HISTORY

NAME (*)

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ADDRESS

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SUBURB

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POSTCODE

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DATE OF BIRTH

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EMAIL (*)

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PHONE (*)

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MOBILE (*)

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HOW DID YOU HEAR ABOUT SOUTH PACIFIC HEALTH CLUB? (select all applicable)
Internet
Friend
Yellow Pages
Signage
Flyer
Newspaper

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HAVE YOU BEEN A MEMBER OF A HEALTH CLUB BEFORE?
YesNo
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ARE YOU CURRENTLY EXERCISING?
YesNo
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IF SO WHAT TYPE OF ACTIVITY?

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IF NO HAVE YOU DONE ANY STRUCTURED EXERCISE?
YesNo
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HOW LONG AGO WAS THAT? (number of months)

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HOW LONG WERE YOU TRAINING FOR? (number of months)

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DID YOU OR ARE YOU GETTING THE RESULTS YOU WANTED?
YesNo
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WHAT TYPE OF EXERCISE INTERESTS YOU? (select all applicable)
Group Fitness
Personal Training
Weights
Cardio
Pilates
Yoga
Swimming

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HOW WOULD YOU DESCRIBE YOUR CURRENT PHYSICAL CONDITION? (*)

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WHY ARE YOU IN THIS CONDITION? (*)

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WHAT RESULTS ARE YOU LOOKING FOR? (select all applicable)
Weight Loss
Improved Fitness
Improved Body Shape
Increased Energy Levels
Increased Strength
Sleep Better
Stress Management
Sports Conditioning

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WHEN WOULD YOU LIKE TO ACHIEVE THESE RESULTS BY? (*)

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HOW IMPORTANT IS IT TO ACHIEVE THESE RESULTS? (*)

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HOW MANY TIMES PER WEEK WOULD YOU LIKW TO TRAIN? (*)

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WHAT TIME OF DAY?
AMPM
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HOW SOON DO YOU WANT TO START? (*)

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WHAT STOPPED YOU FROM STARTING SOONER? (select all applicable)
Work
Family Commitments
No Time
Transport
No Money
Procrastination
Injury

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IS THIS STILL A PROBLEM?
YesNo
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DO FAMILY AND FRIENDS SUPPORT YOU IN STARTING AN EXERCISE PROGRAM?
YesNo
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