Confidential Health Evaluation

Name: City: Birthday: Age:

Email: Phone: FB Contact:

I am interested to:
Lose Weight Gain Weight/Body Build Maintain Weight Improve Health

How long has losing / gaining/ maintaining weight or improving your health been a concern?
___ Week ___ Month ___ Year
What have you tried before?

Why do you feel these other attempts did not work?

Why do you want to lose /gain/maintain weight or improve your health now?

Are you serious about losing /gaining/maintaining weight or improving your health now? Current weight: Ideal weight:

How often do you exercise? Height:

Wake up time: Sleep time: Sleep quality: Bad Average Good Excellent

Eating Habits
Time Type of Food Drinks Fruits Price
Breakfast

Lunch

Tea

Dinner

Supper

Total:
Biscuits / Chips Chocolate Sweets
Smoking habits Soft Drinks/ Water/ ______ / day Coffee / Tea _______ / day

Health Issue
Do you or your family have any of these health-related concerns?
Migraines Sinusitis Joint/Knee/Back Pain(Arthritis)
Asthma Skin Allergies Food Allergies
High / Low Blood Pressure High Cholesterol Heart Problem
Gastric Fatigue / Low Energy Stomach Ulcers
Diabetes Constipation Piles
Any other health concerns, please list (Previous operations, etc) ________________________________________________

BODY SCAN (Date: ______________ ) HEIGHT: ______________cm AGE:__________

WEIGHT BODY WATER MUSCLE PHYSICAL BMR BODY BONE VISCERAL
FAT % RATING AGE MASS FAT
PRESENT

IDEAL

YES, I want to know how to improve my results

YES, I want to offer the free body scan to my friends/ family and receive referral benefits

BODY SCAN (Date: ______________ ) HEIGHT: ______________cm AGE:__________

WEIGHT BODY WATER MUSCLE PHYSICAL BMR BODY BONE VISCERAL
FAT % RATING AGE MASS FAT
PRESENT

IDEAL

Overall rating: Bad Poor Average Excellent _________________________________________________________

Do you know of others whod be interested in getting a complimentary body scan? Yes No
Id like to offer the same service as a gift to the following people:

NAME CONTACT RELATIONSHIP

BEFORE PHOTO TAKEN (Close up of face, full frontal, full side)

DATE WEIGHT B. FAT % WATER MUSCLE PHY. RATE BMR BODY AGE BONE MASS V.FAT

IDEAL