Name *

First Name

Last Name

Phone Number

(###)

###

####

How do you want to feel next year?

Pain free would be heavenly.

I want to keep up or perform better than my daughter. (Hey I'm competitive, what can I say.)

Energy and endurance would be nice. (I'm winded going upstairs at a slow pace!)

I want to get back to my lost loves of...

Biking

Hiking

Running

Swimming

Traveling

Going to the Opera

I know and I dream of how exercise is the missing thing I desperately need, but...

I'm a procrastinator when it comes to anything abdominal, but I did buy that video...

I start out with a bang but then it's hard to stick to a schedule, I'm so busy!

I'm afraid I'll get injured yet again.

Which one describes you?

Weekend Warrioress

I was athletic in a different life. Teens, 20's 30's.

My favorite activity is reading.

How many years since you were exercising regularly?

1 year

2-5 years

10-15 years

Do you have old injuries?

Foot

Ankle

Knee

Hip

Shoulder

Back

Neck

What holds you back from exercise?

Fatigue

Depression

Too complicated

Time

I'd have more time if I didn't have to walk the dog!

How many diets have you been on in the last 10 years?

Paleo

Atkins

Weight Watchers

Other?

Do you have any of the following?

Feeling old, i.e. creaky joints, stiffness in the morning

Low grade back discomfort

Feet hurt

Sluggish

Which of The New You programs are you most interested in?

FIT FOR YOUR NEXT ACT

DELICATE DIVA

JAYNE’S JOINTS

DON'T LOSE A SINGLE POUND

I don't see what I think I need, can you please advise!