Virtual Body Sculpting Questionnaire

Virtual Body Sculpting Questionnaire
Full Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Phone Number
Email
Best Method of Contact
NUTRITION
Do you follow a specific eating style or diet?
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?
If so, please state which ones.
On average, how much water do you drink in a day?
HEALTH & CONTRAINDICATIONS
Do you have any allergies?
If yes, please describe below.
Are you pregnant or breastfeeding?
Do you suffer from heart disease?
Do you have.a pacemaker?
Do you suffer from high cholesterol??
Do you suffer from haemophilia (blood disorder)?
Do you suffer from any liver or pancreatic conditions?
Are you currently undergoing immunotherapy or chemotherapy?
Do you have any scarring, hernias, or skin disorders in the area to be treated?
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)
Where did you hear about us?
Should be Empty:

NUTRITION