Privacy Policy & Liability
(please read thoroughly)
Name
*
First Name
Last Name
Occupation
E-mail
*
Phone number
Birth Date:
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January
February
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Month
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Day
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Year
Current Weight (lbs)
Height (ft/in)
Where did you hear about us?
A Friend or colleauge
Google
Website
Instagram
TikTok
Facebook
Other
What are your health goals?
Nutrition program
workout program
lifestyle coaching
Tele-Medical Consulting
All of the Above
Peptide/ Longevity therapy
Peptide Therapy
Interest(s) in peptide therapy
Energy boost
Weight loss
Muscle growth
Recovery
Other
All of the Above
How much Sleep/day
10+ hours
8-10 hours
7-8 hours
Less than 7hours
How much water do you drink per day?
3+ Liters
2-3 Liters
1-2 Liters
Less than 1 Liter
How often do you eat 'fast food'?
daily
weekly
weekends
monthly
Any Food Allergies? If YES, please list
Current EXERCISE frequency i.e. how many days per week and how long each workout?
How would you rate your physical health/ abilities right now
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
How would you rate your adherence to a fitness/nutrtion program right now?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
How would you rate your mental health right now ?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
How would you rate your medical health right now ?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Medical
Current Medical Condition(s)
High cholesterol
Kidney condition
Glandular fever
Heart/ stroke condition
High blood pressure
Gout
Diabetes
Infectious disease
Breathing difficulties/asthma
Stomach ulcer
Epilepsy
Hernia
Chronic fatigue syndrome
Rheumatic fever
Liver condition
Dizziness/fainting
Pain tightness in the chest
Arthritis
None
Other
Any current Medical complaints today? ( If not seeking medical , then state NONE)
Current Injuries
Neck
Shoulders
Hips
Knees
Wrist
Ankles
Back
None
Other
If any of the previous injuries are marked, please Explain
Are you currently on any Medications? if YES, please list them
What are best Days to schedule wellness sessions?
Mornings Weekdays
Evenings Weekdays
Mornings Weekends
Evenings Weekends
*
I have provided accurate and true details of any medical conditions or injuries I have. I will notify BodyTemple Health & Wellness of any injuries or illness that arise during my time as a member at BodyTemple Health & Wellness and any medications that I am currently taking and all recent medical treatment received by me.(signed by guardian if under 18)
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
*
I have read, understood, and accepted the PRIVACY POLICY for membership.
statement
*
Address:
*
Street Address
Street Address Line 2
City
State
Postal Code
Submit Application
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