Nutri-Fit Studio
Name
Surname
Gender
Blood Type
Date of Birth
Age
Cell Number
Home Number
Email
Address
Physician Name & Surname
Physician Contact Number
Height (cm)
Current Weight (kg)
Current Body Fat Range
Are you currently pregnant? (Females only)
Main aim for this program General FitnessHealthier lifestyleMaintenanceWeight lossWeight gainDefinitionCompetition prepBulkingRehabilitationOther
If Other, please specify:
Specific goal you want to achieve
What specifically do you want to improve?
How long have you been exercising?
Have you exercised at least 2x/week for last 3 months?
Weight training, cardio, or both?
Are you monitoring eating habits?
If yes, how?
Do you eat a healthy diet? YesNoPartially
On a typical day do you eat: Not enoughEnoughToo much
How much water do you drink per day?
What time do you normally wake up?
How long after waking do you eat and what?
Describe your food habits (breakfast, lunch, dinner, snacks)
Allergies
Major surgeries (list)
Ever advised not to do strenuous exercise? YesNo
If yes, elaborate
Any physical disability? YesNo
If yes, explain
Are you on any chronic medication?
What do you do for a living?
Foods you like
Foods you dislike
What sacrifices will be needed to reach your goal?
Additional information you want to share
Signature (type full name)
Date
Parent/Guardian Signature (if under 18)
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