Body Sculpting - Pre-Client Survey

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
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
Would you consider your experience in strength training:
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
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
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:
* Address:
* City: * State: * Zip:
* Phone:
* Email:

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