Wellness Assessment Form - Peak Community Wellness

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Wellness Assessment

Step 1 of 2

50%

Name*
Today’s Date:*
MM slash DD slash YYYY
Cell Phone*
Age*
Email*
Are you currently exercising?*
If yes, what are you doing and how many times a week?*

Features of Interest*
- Infinite 30
- Crossfit
- Personal Training
- Group Exercise
- Tanning
- Recovery/Infrared Sauna/Red-light
- Silver Sneakers
Mark all that apply
Results Desired - Lose weight*
- 10 lbs
- 20 lbs
- 50+ lbs
Other Results Desired*
- Build Muscle
- Less Stress
- Improve Medical Report
- More Energy
- Improve Sleep
- Hot Flashes Gone
- Nights Sweats Gone
Mark all that apply
This entry authorizes Infinite 30, Peak Community Wellness to contact me by phone, mail, or email regarding my entry or special invitation. The information provided by Infinite 30, Peak Community Wellness is not intended to treat or cure any disease or to offer any specific diagnosis to any individual.
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OH 45833
419.695.7325
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1880 N. Perry Street, Suite 200 Ottawa, OH 45875
419.523.7325

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