Home and Commercial Gym Equipment | Treadmills | Exercise Cycles

Full Name:		Phone (h):
Email:		Phone (w):
Address:		Phone (c):
		Age:
		Birthday:

Are you looking to lose some weight? If so, how much?		kg
What other programs / products have you tried in the past?
Why do you feel that these other program(s) did not work?
Do you have cellulite that you want to get rid of?
Do you eat three meals a day?
If no, which meal do you skip?
Do you have a problem with snacking?
If yes, at what time of the day or evening is it hardest to control
What is your favourite snack?
Where do you carry most of your unwanted weight
Do you take vitamins or any type of nutritional supplements?
How many glasses of water do you drink daily?
Do you eat out regularly (more than twice a week)?
Where is your energy level, on a scale of 1 to 10?
Are you currently taking any prescription medications?

Acne :

Alcohol Consumption :

Allergies :

Anaemia :

Arthritis :

Asthma :

Back or Joint Pain :

Caffeine Consumption :

Cancer - Type :

Cellulite Accumulation :

Chronic Constipation :

Chronic Fatigue :

Circulation (poor) :

Diabetes :

Gout :

Headaches :

Heartburn :

Heart Disease :

Blood Press :

Cholesterol :

Hyperactive / ADD / ADHD :

Sinusitis :

Insomnia :

Energy :

Menopausal :

Migraine :

ME :

Mood Swings :

MS :

Nursing Mom :

Osteoporosis :

PMS :

Pregnant :

Sick Child :

Skin Disorder :

Sleep Disorder :

Smoking :

Stress :
Low/Med/High

Ulcers :

Excema :

Psoriasis :

OTHER (PLEASE DESCRIBE):