Medical & Info Form
For The Mind Mastery Program
Full Name
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First Name
Last Name
What is your age?
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What is your gender?
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Please Select
Male
Female
N/A
Contact Number
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Email Address
*
example@example.com
1. Are you currently taking any medication?
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Yes
No
Please list them.
2. Do you smoke or have smoked?
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Please Select
Yes
No
What kind of tobacco products? How long have you used/been using them? Vape, weed etc.. How much $ value p/w?
3. How often do you consume alcohol?
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What type and how much? How much $ value p/m?
4. Are you taking any supplements now? How about in the past?
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Please Select
Yes
No
For fat burning, muscle building, overall health?
What type of supplements are you taking/have you taken? What's the $ value over the past 5 years?
Protein powder/bars, creatine, fat loss pills, multi vitamins, greens powder, probiotics?
5. Do you drink coffee? How many daily/weekly?
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With what type of milk and sugar?
6. What do you do for work and how active is it?
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Office, tradie etc..
7. What do you do currently to stay active?
Walking, gym, hiking, sports, running, swimming, yoga etc...
8. Is there any reason you think you won't be suitable to join?
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Injury, finances, medical issues, family concerns, mental health issues?
9. Have you ever considered surgery to change your body?
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Please Select
Yes
No
Liposuction, plastic surgery, stomach tying etc..
What have you considered or tried? What's the $ value?
10. Have you ever had a doctor or other medical professional diagnose you with a medical condition that stops you from getting into shape?
*
Please Select
Yes
No
Thyroid, back injury, rotator cuff tear etc...
What do you think about this diagnosis? How will it affect you moving forwards?
11. Have you been wanting to change your body for more or less than 10 years?
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12. How many gyms or training centres have you joined trying to change?
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What's the $ value over the past 10 years?
13. How many pts or coaches have you hired before?
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What's the $ value over the past 10 years?
14. How many books or PDFs have you read in regards to fat burning and staying in shape?
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What's their total $ value?
15. How many hours of videos about fat loss and health do you estimate you’ve watched?
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16. What's the approximate total $ value you’ve spent on trying to get your desired results?
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17. What's the top 2 reasons why you think none of the above worked?
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18. What's the best times and days for you to have your compatability call? What's your facebook profile name? (so we can organise)
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Also feel free to directly reach out to the Mind Mastery Facebook page
Anything else you'd like to add?
Complete
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