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Your Name*

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Member Number*

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Current Exercise Regimen

On a regular basis, how many days a week do you devote to cardiovascular exercise, strength training, and/or flexibility? Please expand below.

Cardiovascular:

Strength:

Flexibility:

Which of the following cardiovascular exercises/machines have you used? (please check)

Treadmill

UBE

Elliptical

Rower

Aerobics

Stair Stepper

Nu-Step (Seated)

Swimming

Recumbent Bike

Spinning

Water Aerobics

Upright Bike

Sports

Which of the following resistance training methods have you used?

Free Weights

Weight/Selectorized Machines

Bodyweight Exercises

Have you participated in a structured exercise program in the past?

Yes

No

If you answered YES, how long have you participated?

Do you have any physical limitations that might prevent you from doing resistance or cardiovascular training? (Please list any exercises or machines that aggravate existing conditions or those you prefer to avoid in your program)

How many days per week and how much time per session do you have to devote to resistance training? (Please check appropriate days per week and time per session)

1day/week

2days/week

3days/week

4days/week

5days/week

6+days/week

20 min

30 min

40 min

50 min

60 min

60+ min

How many days per week and how much time per session do you have to devote to cardiovascular training? (Please check appropriate days per week and time per session)