Virtual Body Sculpting Questionnaire

Virtual Body Sculpting Questionnaire
Full Name*

First NameLast Name
Gender

MaleFemale
Date of Birth*

MonthDayYear
Phone Number
Email
Best Method of Contact
NUTRITION
Do you follow a specific eating style or diet?

YesNo
If so, explain.
How many caffeinated beverages do you consume in a day?
How many times a week do you consume alcohol?
How often do you snack on a daily basis?
Around what time in the evening do you stop eating?
Do you take any supplements?

YesNo
If so, please state which ones.
On average, how much water do you drink in a day?
HEALTH & CONTRAINDICATIONS
Do you have any allergies?

YesNo
If yes, please describe below.
Are you pregnant or breastfeeding?

YesNo
Do you suffer from heart disease?

YesNo
Do you have.a pacemaker?

YesNo
Do you suffer from high cholesterol??

YesNo
Do you suffer from haemophilia (blood disorder)?

YesNo
Do you suffer from any liver or pancreatic conditions?

YesNo
Are you currently undergoing immunotherapy or chemotherapy?

YesNo
Do you have any scarring, hernias, or skin disorders in the area to be treated?

YesNo
If you have any diagnosed health problems list the condition(s).
BODY GOALS
What is your current weight?
Which kind(s) of exercise/movement do you do and for how long?
Which body part would you like to work on first?
Are you able to commit to a routine body sculpting schedule?
How much time would you be willing to allocate to yourself for an evening routine?
Please rate your readiness for change (1: not ready - 10:when can we start)

12345678910
Where did you hear about us?

Tik TokInstagramFacebookBooking WebsiteFriend/Family Referral
Should be Empty:

Virtual Body Sculpting Questionnaire

NUTRITION

HEALTH & CONTRAINDICATIONS

BODY GOALS