NEW EN Step 1: Health Questionnaire

Step 1: Health Questionnaire
Date

DayMonthYear
Date
Name:*

First nameLast name
Address*

Street / Hause number

Street Address Line 2

CityState / Province

PostcodeCountry
Date of birth*

DayMonthYear
Date
Age*
Occupation*
Brief description of everyday activities*

Height in cm:*
Start weight*
Target weight*
Body fat content in %:
I don't know my body fat percentage.

Your top 5 goals
Goals that motivate you and drive you?
(Health, visual, performance-oriented...)

1.
2.
3.
4.
5.

Your transformation as inspiration for others!
How would you like us to share your transformation on Social Media?

Everything can be shownBody without your head can be shownParts such as Tattoos should be coveredOther
How would you like to be mentioned?

With first and last nameOnly first nameWith another random name to stay anonymousMy Social Media can be linkedPlease type your social media accounts that should be mentioned:

Further Health Information
Any chronic Illnesses?*

YesNo
Info
Do you take any medicine?*

YesNo
Info
Have you recently had an illness or surgery?*

YesNo
Info
Do you smoke?*

YesNo
If so, how many cigarettes per day?
Sleep habits / hours per night?*
How much water do you drink every day? (liters)*