Download the Fit by Wix app and use code: FITBYCALLIE

Personalized Program Questionnaire

Name

Phone Number

Are you continuing a FitbyCallie personalized program? *

Yes

Have you been working out for the last 6 months? *

Yes

How many days per week do you plan to workout

How long do you have to workout each time?

Fitness Goals (Check all that apply):

Strength

Build Muscle

Weight Loss

Overall Health

Postpartum

Other (Describe below):

Workout Location *

Gym

Home

Medical History (check all that apply) *

I have had a heart attack

I have a heart condition

I experience pain or discomfort in the chest at rest or during exercise

I tend to lose consciousness or fall as aresult of dizziness

I experience claudication (lower leg pain from knee to ankle relieved by rest)

I have had a stroke

I have high cholestrol

I have Type 1 or Type 2 diabetes

I have lung disease (Emphysema, Asthma, wheezing, COPD, etc.)

I have a neuromuscular disease (Parkinson's, MS, Epilepsy)

I have muscle, bone, or joint problems that I feel would limit my participation in an exercise program

I have had surgery

I am currently pregnant

I smoke

I have other reasons i should not exercise without medical supervision (Explain below)

None of these options apply to me

Describe any physical limitations you have

I agree to the terms outlined in theRelease of Liability

Callie cell

bottom of page