Plan B Health Form

Plan B Health Form

Welcome to the Plan B Health Lifestyle. Please fill out the quick form below. Ms. Barbara Regeana Taylor will begin your New Plan B Weight Loss Journey Against Obesity!
1) Your Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
2) Email*
example@example.com
Phone Number*
Please enter a valid phone number.
3) On a scale of [ 100-1000 lbs ] where do you fit in?*
4) CONDITIONS: Please list any underlying conditions that will affect your ability to exercise or diet:*
Include Any Physical, Mental or Medical Conditions and Food Allergies etc.
5) Goals: What are your short-term health goals?*
6) When was your last Dr's visit?*

Less than 6 months ago6 months - 1 year1 year - 5 years5 years or moreNot sure
7) Do you have a support team?*

DieticianGeneral DoctorHealth AdvisorCertified NutritionistPhysical TherapistNone of the above
8) Have there been any injuries to the back, head, knees, arms, or legs that will prevent certain exercises?*

YesNoNot sure
9) Please list the injuries
10) I, undersigned, agree with the following statements:*

I am the client and all information above is deemed true.I release Ms. Barbara Taylor and any affiliates thereof from all responsibility of any incidents, accidents, physical falls, allergic food reactions, and or personal injuries that may occur during weekly exercise routines managed and directed by Ms. Barbara Taylor as the Plan "B" Health Program.
11) Date*

MonthDayYear
Date
12) Your Signature: Plan B is Better, and affiliates have the right to be selective. Your health information shall never be shared or sold to third parties without the written consent of the client. Thank you for your cooperation. Let's Do The Work!*

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