DIY Workout Program

DIY Workout Program

Thank you for taking out the time to fill this form. Your honest answers will help in creating the right workout program for you. This information will be kept confidential.
Client Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Email*
example@example.com
Occupation*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
How would you rate your current level of physical activity?*

Sedentary/very inactive (no exercise at all)Somewhat inactive (once a week)Average (twice a week)Fairly active (three times a week)Extremely active (four - six times a week)
If you selected ‘somewhat inactive’ or above, please the type of exercises that you do.
When was the last time you worked out?
On a scale of 1 to 5, how would you rate your level of stress?*

1

2

3

4

5

1 is , 5 is
On average, what is your energy level like most days?*

Low energyModerate energyHigh energy
What does your daily routine look like? This includes your waking and sleeping hours, and your mealtimes. Please include time stamps. *
Please provide a detailed breakdown of what one day of meals looks like for you. This should include what you eat for your main meals as well as snacks. Please include time stamps.*
Please share your fitness goals below. *

Please select the conditions that have affected your health either recently or in the past. *

	Yes	No
Broken/dislocated/fractured bones
Muscle strain/sprain
Arthritis or bone-related diseases
Diabetes type 1
Diabetes type 2
High blood pressure
Low blood pressure
Insomnia
Anxiety/depression
Surgery
Eye problems
Pain in any part of the body
Pregnancy
PCOS/any other hormonal problem
Poor mobility/movement limitations in any part of the body
Asthma/any other respiratory weakness
Heart problems
Spinal disorders
Cancer
None

If you selected any of the above conditions, please provide more detail (e.g. time of diagnosis, symptoms and any other details your personal fitness trainer should know
If there is anything else you want to share, please do so below:
Your weight*
In KG
Your height*
in feet and inches

Using a measuring tape, kindly measure yourself in the following areas and write down the values below*

	In inches
2 inches above belly button
On the belly button
2 inches below belly button
Hips
Thigh
Bicep (this must be done with your arm straight)

Please select your plan of choice*
prevnext( X )
20-day program5 workouts/week
26,000PKR



16-day program 4 workouts/week
20,800PKR



12-day program3 workouts/week
15,600PKR



Total

0.00PKR
All payments are made through direct bank transfers. Please attach a screenshot of your payment receipt after completing it. *

Cancelof
Bank: Allied Bank Limited

Account name: Mariyah Bintey Imran

IBAN No: PK74ABPA0010058379140010
Terms and Conditions
1. If at any point the client feels unwell and/or experiences pain or discomfort, she must notify the instructor immediately. This includes any rising medical conditions that the client feels may affect or be affected by doing exercises.
2. The client must notify the instructor when she is on her period or is pregnant. This is to ensure the safety and wellbeing of the client. Some exercises/poses can not and should not be done during both conditions and must not be taken lightly.
3. Keeping in mind the unpredictable nature of clients’ work and home lives, a workout may be moved to another day if notified in time.
4. Whether the client is assigned a 45-minute workout or less, the monthly cost will remain the same.
5. Payments must be made in advance and are non-refundable.
6. Monthly charges are subject to change.
7. A client may postpone 1 week’s workouts. Any sessions postponed beyond that number will not be rescheduled to another day.
8. The client must utilise her workouts within 5 weeks of the purchase date. A new cycle of workouts will begin after 5 weeks.
9. The client must not combine Mariyah’s workout plans with any other workout plans. If she intends to do so, she must first discuss it with her trainer as it could lead to overtraining and as a result, injuries.
10. Medical and contact information (and any other private information shared during weekly check-ins) of the clients is confidential and is not shared with any other person.
11. The client may share the instructor’s personal contact information with potential clients.
12. Any feedback and constructive criticism from the client is highly appreciated and will help in improvement of services.
13. Addition of new policies or changes to existing policies will be applicable on clients from their new billing month.
I agree to the terms and conditions listed above.
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DIY Workout Program

Terms and Conditions