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
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First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
2) Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
3) On a scale of [ 100-1000 lbs ] where do you fit in?
*
Please Select
100-250
250-350
350-500
500 (+)
Not sure
4) CONDITIONS: Please list any underlying conditions that will affect your ability to exercise or diet:
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Include Any Physical, Mental or Medical Conditions and Food Allergies etc.
5) Goals: What are your short-term health goals?
*
Please Select
Lose weight
Eat Healthy
Exercise
All the above
6) When was your last Dr's visit?
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Less than 6 months ago
6 months - 1 year
1 year - 5 years
5 years or more
Not sure
7) Do you have a support team?
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Dietician
General Doctor
Health Advisor
Certified Nutritionist
Physical Therapist
None of the above
8) Have there been any injuries to the back, head, knees, arms, or legs that will prevent certain exercises?
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Yes
No
Not sure
9) Please list the injuries
10) I, undersigned, agree with the following statements:
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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
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-
Month
-
Day
Year
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!
*
Submit
Submit
Should be Empty: