top of page
Exercise Express Survey

Office use: (Required)

Did the client sign the liability waiver form?

Please answer following question to the best of your ability.

How confident are you that you can manage your overall Very confident personal health?

In your opinion, how much do each of the following factors contribute to a person's overall health?

Reducing stress
In general, how would you rate your health?
How physically fit do you currently feel?
How physically fit do you currently feel?
On a typical day, how many times do you eat fruit (not Never including juice)
On a typical day, how often do you eat vegetable of any type (either cooked or raw

How often do you do each of the following?

Exercise in ways that are appropriate to your level of ability:
Get physical exercise that goes beyond your typical Often day-to-day activities:
Feel stress:
How much water would you say you drink a day? (8 oz bottles)
bottom of page