HEALTH AND FITNESS SURVEY

Health and Fitness Survey

First Name:

Last Name:

Street Address:

City:

State

Zip:

Email Address:

Phone:

Age:

Gender:	Household income:	Marital status:

Number of Children:
Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender Age Gender

Please tell us which of the outdoor activities you are involved in:

Nautilus	Fitness Training	Dance
Free Weights	Tennis	Racquetball
Running	Golf	Bicycling
Walking	Swimming	Nutritional Supplements
Pilates	Aerobics	Vitamins
Yoga	Weight loss

How often do you participate in this fitness activity?

Are you currently a member of a fitness facility?
Yes
No

Do you prefer to exercise at:
Home	Yes	No
Fitness Facility	Yes	No

Do you currently own:
	Fitness equipment
	Instructional exercise videos
	Fitness magazines

Are you currently taking:
	Nutritional supplements
	Vitamins
	Both

Do you have an interest in learning more about
	Nutritional supplements
	Vitamins
	Both

Thank you for your time. The information you provided will help us bring you only targeted offers that will save you time in your busy schedule.

Unless you have checked any of the boxes above, we'll assume that you do not mind receiving online or postal offers.

I would prefer not to receive online offers, product information, specials, updates from third party advertisers

I would prefer not to receive postal offers, product information, specials, updates from third party advertisers