Survey Form

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Please answer these questions so I may better understand your personal situation, background and goals.

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What is your gender? Male Female

What age group are you in? I am in my 20's I am in my 30's I am in my 40's I am in my 50's I am in my 60’s I am in my 70’s or older

Are you a health & fitness professional? Yes No

What is your main health & fitness goal? Lose Weight/Fat or Get In Shape Get Stronger or Build Muscle Overcoming Current Injuries Longevity, Safe Training and Energy

What pain or injury do you need help with? (choose one or more): Neck Pain Shoulder Pain Elbow Pain Wrist & Hand Pain Back Pain Hip Pain Knee Pain Foot & Ankle Pain

Do you have any health concerns? Do you have/are you concerned about Diabetes? (CHECK IF APPLIES) Do you have/are you concerned about Alzheimer’s? (CHECK IF APPLIES) Do you have/are you concerned about Heart Disease? (CHECK IF APPLIES) Do you have/are you concerned about Muscle Pain? (CHECK IF APPLIES) Do you have/are you concerned about Vision Health? (CHECK IF APPLIES) Do you have/are you concerned about Joint Pain? (CHECK IF APPLIES)

Where do you live? USA Canada Europe Mexico Central or South America Australia or Surrounding Area Asia or Africa

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