ENTER INFO
How did you learn about the program?*
Date
Name*
Mobile number*
Email address*
Zip Code*
Which wellness programs are important to you?
Emotional
Environmental
Financial
Intellectual
Occupational
Physical
Social
Spiritual
What is your classification?
Pittsburgh Yards Tenant
Pittsburgh Yards Co-Working Member
Employee (Area Business)
MLK Middle School
Household status
Single
Spouse/Partner
Child(ren)
Pet(s)
Have you worked out consistently (3 to 5 times per week) for 3 yrs?
Yes
No
Never got close
Is your job physical demanding or do you spend a lot of time seated?
Active
Seated
Would you describe yourself as (choose one)*
Active
Sedentary
Will you use the Atlanta Beltline to access Pittsburgh yards?
Yes
No
50/50
Have you been able to achieve good results with consistent and training and eating habits in the past?
Yes
No
First attempt
What would you like to achieve from your fitness program?*
To Get Active/Reactive
Increase Endurance/Stamina/Metobolism
Decrease Body Fat
Manage Chronic conditions (high blood pressure, diabetes, etc.)
Increase Mobility/Flexibility
Increase Muscle Mass
Increase Muscle Tone
Peace of Mind/Emotional Balance
Increase Weight Loss
Stress Relief
Are you eating 3 meals per day?
Yes
No
Are you anemic?
Yes
No
Do you drink wine/liquor? If yes, how often.
1 to 3 glasses a week
4 to 7 glasses a week
8 to 11 glasses a week
12 or more glasses a week
N/A
Is there anything specific stopping you from starting a wellness program?*
What workouts do you enjoy?
Weight Training
Cardio Training
MetCon Training
Bootcamp Training
Step Class
Plyometrics
Yoga / Tai Chi / Pilates
Tabada Training
Jogging / Running
Speed /Power Walking
Spinning Class
Hiking / Mountain Climbing
emergency contact name*
emergency contact phone*
emergency contact relationship*