EVALUATION FORM
The following questionaire is a comprehensive look at your health. It will take about 5 minutes to complete
Full Name
First Name
Last Name
Gender
Male
Female
E-mail
Phone Number
-
Area Code
Phone Number
Dirección
Dirección de la calle
Dirección de la calle Línea 2
Ciudad
Estado / Provincia
Código Postal
GENERAL INFORMATION
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Height if known
Weight if known
What would you like to achieve with our systems?
*
Fat / inch reduction
Muscle toning / building
Skin tightening (flaccidity)
Cellulite and water retention improvement
Postpartum or post-surgery recovery
Other
Which body areas would you like to focus on?
Abdomen
Glutes
Legs
Arms
Back
Face
Are you currently on on a GLP-1 treatment ( Ozempic, Wegovy, Mounjaro, etc.) ?
*
Please Select
Yes
No
Do you have trouble getting to sleep?
*
Please Select
No
Yes
Do you have to go to the bathroom during the night?
*
Please Select
Yes
No
Do you have known allergies?
*
Please Select
Yes
No
Please list any known allergies ( if not, put none)
*
Please list any supplements you are currently taking
*
Do you have any surgery ?
*
Next: Diet and lifestyle . .
Back
Next
Please list any food allergies / intolerances that you are aware of?
How many glasses of water do you have a day?
*
Do you drink alcohol?
Yes
No
How many per week?
*
Back
Next
Patient health history
Frequency of exercise (days per week):
*
6 - 7
3 - 5
1 - 2
0
Vegetarian or vegen:
*
Please Select
No
Yes
Planning to have a baby in the next 3-6 months:
*
Please Select
No
Yes
Back
Next
Do you diet often?:
*
Please Select
No
Yes
Are you unhappy with your weight?:
*
Please Select
No
Yes
Back
Next
Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness?:
Availability & Commitment
How often could you attend sessions ?
Once per week
Twice per week
Three times per week
Preferred times:
Mornings
Afternoons
Evenings
Would you like us to E-mail you a copy of your HAQ?
*
Please Select
Yes
No
Your Preferred E-mail Address
*
Signature
Enviar
Should be Empty: