B3 LLC
Body By Benton
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Health Questionnaire
Name
*
Email Address
*
Phone
*
What are your primary fitness goals?
*
Weight Loss
Muscle Gain
Flexibility/Mobility
Cardiovascular Endurance
Sport-Specific
Rehabilitation
Describe your current level of physical activity
*
List any past surgeries and medical conditions, along with medication, that I should be aware of.
What motivates you the most? (e.g., seeing results, positive reinforcement, challenging goals)
How would you rate your current stress levels?
Are there any specific exercises or activities you want to avoid?
How do you best learn new information or exercises? (Please check all that apply)
Visual (seeing it done)
Auditory (hearing instructions)
Kinesthetic (doing it yourself)
All The Above
How do you prefer to receive feedback during our sessions? (e.g., direct, supportive, written notes)
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