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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