Name *

First Name

Last Name

Phone

(###)

###

####

Are you able to get up from a chair or toilet without using your arms?

Yes

No

Sometimes

In the past year, have you had a fall or felt unsteady on your feet?

Yes

No

Can you walk for 10 minutes without stopping, with or without a device?

Yes

No

With Difficulty

Do you have any joint pain, stiffness, or weakness that limits your daily activity?

Yes

No

Occasionally

Do you avoid stairs, uneven terrain, or reaching overhead due to fear or discomfort?

Yes

No

Sometimes

Has your doctor ever recommended that you begin or continue exercise?

Yes

No

I'm not sure

Are you interested in improving any of the following?

Strength

Balance

Flexibility

Pain Management

Energy

Mood

None

Would you like to be contacted for a free consultation or fitness screening?

Yes

Not right now

Maybe later