Social Media Name I.G/Fb
How did you hear about us?
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Personal Information
Full Name
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Contact Number
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Age
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Height (ft - inches)
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Current Weight (lbs)
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Medical Information
Please answer true and correct.
Did your physician recommend that you lose weight and/or start an exercise program?
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Yes
No
Are you taking any medications or drugs?
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Yes
No
If yes above, please list medication, dose and reason.
Are you taking any supplements (e.g. vitamins, minerals, antioxidants, herbal remedies)?
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Yes
No
If yes above, please list.
Do you now, or have you had in the past (diagnosis, treatment and or habits):
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History of heart problems, chest pain or stroke?
High blood pressure (hypertension) or low blood pressure
Increased blood cholesterol
Diabetes (type I or II), thyroid condition or hypo/hyperglycemia
History of breathing/lung problems (asthma, COPD, emphysema)
Obesity (more than 20 percent over ideal weight)
Depression, Bipolar, SAD
Chronic sleep problems
Any chronic illness or condition (cancer, MS, epilepsy, fibromyalgia)
Circulatory problems/conditions
Frequent colds, flu, upper respiratory infection, strep throat
Stomach, intestinal, digestive problems/conditions
Arthritis, Rheumatoid arthritis, osteoporosis
Recent surgery (in past 24 months)
Muscle, ligament, tendon, joint (shoulder, knee, hip, ankle, wrist) neck, or back disorder/injury or any previous injury still affecting you
Cigarette smoking habit
Hernia or any condition that may be aggravated by lifting weights
Women: Do you suffer from problems associated with your menstrual cycle / menopause?
Men: Do you suffer from problems associated with you prostate such as slow urination or waking up at night to urinate?
Women: Pregnant and breast feeding (now or within last 12 months)?
Other
Dietary Habits
Please answer as accurately as possible
How many meals, including snacks do you have in a typical day
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Please Select
1
1-3
More than 3
Do you eat breakfast regularly?
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Yes
No
Do you eat more meals with poultry, lean meat, fish and plant (soy) proteins rather than steaks, roast and other red meat?
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Yes
No
Do you eat a variety of colorful fruits and vegetables?
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Yes
No
Do you eat at least seven servings of fruits and vegetables a day?
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Yes
No
Do you consume primarily whole grains (100% whole wheat bread, pasta and brown rice) rather than regular pasta, white rice and white bread?
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Yes
No
Do you eat ocean caught fish at least 3 times a week?
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Yes
No
Do you avoid the intake of fried foods, dressings, sauces, gravies, butter and margarine?
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Yes
No
Do you stay away from soda and typical snack foods throughout the day and after dinner
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Yes
No
Do you drink at least 8 - 12 glasses of water a day?
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Yes
No
Do you get a minimum of 30 minutes of exercise 3-5 days a week?
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Yes
No
Do you have the energy and focus you need to meet your daily challenges?
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Yes
No
Does you occupation require much activity (i.e. walking, getting up and down, carrying things)?
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Yes
No
How many hours of sleep you get each night?
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Less than 4 hours
4 - 6 hours
7 - 9 hours
over 9 hours
Is your stress levels relatively low or high on a daily basis?
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Low to Medium
Medium to High
Do you usually have time to prepare balanced meals, rather than take out or eat on the run?
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Yes
No
Typical Daily Diet
Wake up Time
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12
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Hour
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10
20
30
40
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Minutes
AM
PM
AM/PM Option
Breakfast
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1
2
3
4
5
6
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10
11
12
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Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Snack
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2
3
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5
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10
11
12
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Hour
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10
20
30
40
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Minutes
AM
PM
AM/PM Option
Lunch
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2
3
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10
11
12
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Hour
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10
20
30
40
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Minutes
AM
PM
AM/PM Option
Dinner
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10
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12
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Hour
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10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What type of snacks you have?
Chips
Fast food
Candy/Sweets
Soft Drinks
Fried Food
Other
Goal Evaluation
Rank your goals in starting this program, by using the following scale to rate each goal.
Body fat loss (weight loss)
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1
2
3
4
5
Improved cardiovascular fitness
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1
2
3
4
5
Reshape or tone body
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1
2
3
4
5
Build Muscle
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1
2
3
4
5
Improve Flexibility
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1
2
3
4
5
Improve Performance for a specific sport
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1
2
3
4
5
Improve moods and ability to cope with stress
1
2
3
4
5
Increase energy levels
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1
2
3
4
5
Ensure workouts are fun
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1
2
3
4
5
Maintain my workout consistency
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1
2
3
4
5
Thank you for completing your free online wellness profile you will be contacted within 24-48hrs for results &consultation
SUBMIT
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