Name

First Name

Last Name

Date of Birth *

Date of Birth

YYYY

Weight

Height

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address *

Occupation

Physician

Physician's Phone

(###)

###

####

Have you ever been diagnosed with:

In an effort to effectively assist with nutritional planning, some basic health information is asked for within this form. This is voluntary information and you may refuse to fill out certain parts of this form, however, false or incomplete information may pose a threat to your health for which we cannot be responsible. Please feel free to contact us to clarify anything necessary in completing this form.

Heart Disease

High Blood Pressure

Hypertension

Cancer

HIV/AIDS

Diabetes

Are you:

Pregnant

On any medications

On any medical restrictions

Receiving medical treatment

Please explain any “Yes” questions here including dates: *

Please list any other medical or health conditions not listed above that may require consideration in your participation in a weight-loss or fitness program including orthopedic: *

Please describe your diet and an average day of eating: *

Briefly describe your current level of activity and your health and weight goals: *

By signing this intake form, I guarantee this information is true to the best of my knowledge and I agree to the above terms and conditions stated in the waiver.

Electronic Signature

INTAKE FORM

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