Language
English (US)
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Name
*
First Name
Last Name
Age
*
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
*
This is the email where I will send you your routines/meal plans
Phone Number
-
Area Code
Phone Number
Occupation
Are you currently taking any exercise program?
Yes
No
Height (in)
*
Weight (lbs)
*
Do you have the following conditions?
Anemia
Arthritis
Asthma
Cardiovascular problems
Diabetes Mellitus
Hypertension
Glaucoma
Bone problems
Respiratory issues
Migraine
Other
Are you a smoker?
Yes
No
Are you pregnant (Female only)?
Yes
No
Do you drink alcohol?
Yes
No
How many times do you exercise in a week?
Do you eat 3 meals a day? (Breakfast, Lunch, Dinner)
Yes
No
What do you usually eat in breakfast?
What do you usually eat in lunch?
What do you usually eat in dinner?
What do you usually eat as a snack?
Have you had any injuries in your body? If yes, please indicate the location and date:
Did you undergo any surgeries in the past? If yes, please indicate the type of surgery and date:
What are your goals in this program?
Fat loss
Gain muscle mass
Be physically fit
Sport performance
Improve overall health
Write down your top 3-5 personal health goals:
How much time in a week can you provide in this program?
Client Signature
Date Signed
-
Month
-
Day
Year
Date
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