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👤 Basic Information

Your Name *

Email Address *

Date of Birth

Height (inches)

e.g., 5'6" = 66 inches

Weight (lbs)

🎯 Your Goals

What are your top 1–3 goals? (Select any that apply)

Feel better day-to-day / more energy Reduce pain/stiffness / move easier Weight loss / body composition Improve cardio fitness / endurance Improve strength (daily-life strength) Balance / fall prevention Mobility / flexibility Condition for a specific event (trip, hike, surgery prep, etc.) Other

If "Other", please describe:

🏥 Medical Safety (Important)

Any medical restrictions or "do not do" instructions?

List any exercises or movements your doctor has told you to avoid.

Any serious medical conditions that affect exercise?

Include conditions like heart disease, diabetes, arthritis, recent surgeries, etc.

📊 Current Activity Level

What can you do comfortably right now?

Walk continuously (minutes)

Climb stairs (flights)

Stand comfortably (minutes)

Can you carry groceries?

Yes No

Can you get out of a chair without using your hands?

Yes No

📅 Schedule & Logistics

Preferred workout days (select all that work for you):

The number of days you select will determine how many days per week you exercise.

Sun Mon Tue Wed Thu Fri Sat

Date for next workout day

When would you like to start your exercise plan?

Typical session length (minutes)

How long do you want each exercise session to be?

📧 What happens next? Please submit this form and you will receive an email when your plan has been prepared.

⚠️ Important Health Disclaimer

This exercise program is for informational purposes only. Always consult your healthcare provider before starting any exercise program, especially if you have chronic conditions, recent surgeries, or other health concerns.

Sign Up for WorkoutAgenda

👤 Basic Information

🎯 Your Goals

🏥 Medical Safety (Important)

📊 Current Activity Level

🏃 Exercise Preferences

📅 Schedule & Logistics

⚠️ Important Health Disclaimer