DREAM YOUR SHAPE, SHAPE YOUR DREAM©

  
INITIAL HEALTH SURVEY
* required field
   
NAME*
ADDRESS
 
TOWN / CITY
COUNTY / STATE
COUNTRY
POST CODE / ZIP
   
TELEPHONE*
E-MAIL ADDRESS*
   
OCCUPATION*
BRIEF JOB DESCRIPTION
WEIGHT*
AGE*

HAVE YOU HAD ANY OF THE FOLLOWING ?

PLEASE TICK RELEVANT BOXES
RECENT SURGERY 
PAST HEART TROUBLE 
OFTEN FAINT OR DIZZY 
HIGH BLOOD PRESSURE 
REFORMED OR PRESENT HEAVY SMOKER 
BONE, JOINT, LIGAMENT OR TENDON PROBLEMS 
IMMEDIATE FAMILY MEMBER SUFFERED HEART ATTACK BEFORE AGE 50 
TAKING MEDICATION 
SUFFER FROM FOOD ALLERGIES OR ASTHMA 
PREGNANT 
DIABETIC 
HYPOGLYCAEMIC. (LOW BLOOD SUGAR/ENERGY) 
OVERWEIGHT AND NOT ACCUSTOMED TO EXERCISE 
ANY LIVER OR KIDNEY PROBLEMS 
DO YOU DRINK HEAVILY 
DO YOU SUFFER FROM ANY KNOWN DIGESTIVE PROBLEMS 
ARE YOU FOLLOWING A SPECIAL DIET FOR ANY OF THE ABOVE 
 

If you have answered yes to any of these questions or are over 35 years old, it is wise to seek a doctor’s advice before a change of "diet" or beginning an exercise programme. The doctor should take your pulse, temperature and blood pressure.

 

Please enter below your specific details. These are confidential.

  
What are your goals? weight/fat loss muscle with fat loss muscle gain

note:

  If you are slightly overweight it is best to select weight / fat loss to begin with.

 

  
YOUR HEIGHT Metres   or    Feet
ACTIVITY LEVELS AT HOME*
ACTIVITY LEVELS AT WORK*
ACTIVITY LEVELS AT PLAY*
WILL POWER*
MEALS / DAY*
MILK PER DAY FOR CEREAL TEA etc.*
PREFERRED METHOD OF WEIGHING FOODS TO BEGIN WITH.*
ADDITIONAL COMMENTS

I have read and answered the above and declare that the medical information above is 100 percent correct and accurate to the best of my knowledge.

 

 
 

     Disagree
       
   

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