EmailMeForm
Please fill out the form below. A confirmation email will be sent to you after completion.
Our Health History Form is required for 5 & 7 Day Basic Plans.
Name:
*
First
Last
Date of Birth:
*
MM
/
DD
/
YYYY
Sex:
*
Address:
*
Street Address
City
State / Province / Region
Postal / Zip Code
Phone:
*
###
-
###
-
####
Email:
*
Medical conditions a doctor has diagnosed:
Height:
Weight:
Do you exercise?
Yes
A little bit
No
Please explain your activity during the day. What kind of cardio activity do you engage in?
Frequency (How many days?)
Duration (How long?)
Modality:
Intensity (How fast,level)
If you engage in strength training, please explain training session: How many days per week?
How many sets do you do?
How many reps do you do?
Do you do a body part each day?
Do you participate in a class?
What kind of class?
How many days?
How many meals do you eat out weekly?
What liquids do you consume in a day, i.e. milk, protein shake etc.?
Is there anything you CAN'T live without?
Do you drink alcohol?
Yes
No
What do you drink?
How often do you drink?
How many drinks per week?
What health and wellness goals do you want to achieve with this program?
