GOALS QUESTIONNAIRE GOALS QUESTIONNAIRE This questionnaire is designed to help identify specific wellness goals that can help pinpoint the most effective and efficient program for you. Participant's Name: Date: Areas I want to improve: Aerobic endurance Strength Flexibility Improve balance & coordination Improve eating habits Improve posture Pain elimination/management Other (specify): Specific sport ability: Injury rehabilitation: Back Problem: Sleep better: (more/less?) Specific job ability: Reduce Blood Pressure: Improve self-esteem: Improving my pain/fitness/wellness levels is extremely important to me because… Have you participated in a fitness/wellness or physical therapy program before? If yes, please describe. I was most successful in my fitness programs when… I am committing myself to my fitness/wellness program because otherwise I would have to live with the following unbearable consequences (ex. low self-esteem, limited success, dependency upon others, etc.) What I would most like to achieve from my new movement program is… Equipment available: How much time available for sessions with Dot: How much time available for working on my own in-between: If you are human, leave this field blank. Submit Δ
