Full Name
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Email
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Phone
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Age Group
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Age Group
Under 40
40-50
51-65
66-75
76+
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What Is Your #1 Goal Right Now?
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What challenges are currently holding you back?
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Joint pain or stiffness
Lack of energy or motivation
Balance issues/fear of falling
Muscle loss or weakness
Breathing difficulties
Concern about future independence
Other:
How soon are you looking to get started?
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How soon are you looking to get started?
Immediately
Within 1–2 weeks
Next month
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