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Lifestyle Form
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Anticipated Start Date
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YYYY
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Name
*
First
Last
Birthday
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DD
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13
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15
16
17
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31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
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1984
1983
1982
1981
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1979
1978
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1972
1971
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1968
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1965
1964
1963
1962
1961
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1952
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1932
1931
1930
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1928
1927
1926
1925
1924
1923
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1921
1920
Gender
Male
Female
Phone
Email
*
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Occupation
Smoker? How many per day
Units of alchol per week:
Current Weight
Ideal weight and when last at this weight
Heaviest weight
Height
Waist (inches and cm) at your navel
Hips (inches)
Hours of exercise per week
Type of exercise
Medical history/health concerns/medication
How would you describe your overall wellbeing right now
Any digestive problems? (e.g. heartburn, bloating, wind etc)
What nutritional supplements do you take?
Rate your eating
Selected Value:
0
1 is unhealthy - 10 healthy
Stress Levels
Selected Value:
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1 is low - 10 high
Energy Levels
Selected Value:
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1 is low - 10 high
Concentration Levels
Selected Value:
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1 is low - 10 high
Self-esteem
Selected Value:
0
1 is low - 10 high
Sleep quality
Selected Value:
0
1 is low - 10 high
Skin health
Selected Value:
0
1 is poor - 10 good
PMS/menopausal symptoms
Selected Value:
0
1 is poor - 10 No symptoms
Craving Levels
Selected Value:
0
1 is low - 10 High
What would you like to achieve: Health, Weight, Fitness
By when? Do you have a specific goal in mind?
What are your top 3 reasons for wanting to change now?
What are the top 5 most important things to you in your life?
List all the advantages of you achieving your goals now. How will your life improve?
Please provide details of other healthy eating regimes you have tried
What usually gets in the way of your success / what are your barriers?
How can you overcome these barriers?
What are your biggest concerns regarding your health / weight?
What is the best way to support you? What do you most need?
What are your hobbies – what do you love doing?
What other areas of your life would you like to improve?
On a scale of 1 (low) to 10 (high) how important is it for you to be healthier:
Selected Value:
0
On a scale of 1 (low) to 10 (high) how important is it for you to be slimmer:
Selected Value:
0
On a scale of 1 (low) to 10 (high) how important is it for you to be fitter:
Selected Value:
0
On a scale of 1 (low) to 10 (high) how committed do you feel towards your goals?
Selected Value:
0
Do you have any other questions, anything else you would like to mention?
Signature
Clear Signature
Please read the following carefully and sign above if you agree: We are not a medical organisation and the information and reports generated by us should not be interpreted as a substitute for a medical consultation. Nothing contained in the programme should be construed as medical advice or diagnosis. It is your responsibility to determine, What would you like to achieve: Health Weight Fitness By when? Do you have a specific goal in mind? What are your top 3 reasons for wanting to change now? What are the top 5 most important things to you in your life? List all the advantages of you achieving your goals now. How will your life improve? Please provide details of other healthy eating regimes you have tried What usually gets in the way of your success / what are your barriers? How can you overcome these barriers? What are your biggest concerns regarding your health / weight? What is the best way to support you? What do you most need? What are your hobbies – what do you love doing? What other areas of your life would you like to improve? On a scale of 1 (low) to 10 (high) how important is it for you to be: Healthier: Slimmer: Fitter: On a scale of 1 (low) to 10 (high) how committed do you feel towards your goals? through obtaining appropriate medical advice, that you are fit and well and that such contents and services are suitable for you. It is not our responsibility to do so. Please seek advice from your doctor if you're in any way concerned about your health, you are very overweight, before commencing any exercise regime, if you have an existing medical condition that could be affected by dieting, if you believe you have an eating disorder, or if you are pregnant or planning a pregnancy. The programme is not intended for those under the age of 18 without consent from a parent, doctor or guardian.
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