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Chrome Divas Pole Dance & Fitness Studio
Free Assessment Form
Name
Last name
Age
Your email*
What is your Height*
Current Weight (lbs)*
What is your goal? (Multiple answers okay)*
Fat Loss
Mental Health
Competition Prep
Sports Event Prep
Lifestyle
Strength
Muscle Gain/Body Recomp
Muscle Gain/Fatloss
Do you have any health issues?*
Yes
None
If yes, please provide health conditions*
Current Working Hours*
Philippine Time
Grave yard shift
Others
Do you exercise?*
Yes, less than 3x a week
Yes, Active 4-6x a week
No, True Couch Potato
No, does walking count?
If you were to be given a choice, what form of exercise will you commit to? (Check all that applies)*
Walking (indoor or outdoor)
Running
Swimming
Home/Gym - Weight training
HIIT or Circuit Training (Home/Outdoors)
Crossfit
Boxing or MMA
Dancing
Badminton/Tennis/Volleyball
Others
For Life Coaching/Wellness, how many hours can you invest in your coaching session per week?*
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