Weight Loss X Participant Form

PARTICIPANT FORM

FULL NAME

PHONE NO.

GENDER

EMAIL ID

CITY & STATE

1. DO YOU EXERCISE? IF YES, HOW MANY YEARS YOU BEEN EXERCISING?

2. DO YOU HAVE ANY INJURY? IF YES, THEN PLEASE EXPLAIN.

3. DO YOU HAVE ANY PRE EXISTING MEDICAL CONDITION? IF YES, THEN PLEASE EXPLAIN

4. DO YOU WORK? IF YES, HOW MANY HOURS? DO YOU WORK AT HOME OR OUTSIDE?

5. DO YOU TRAVEL REGULARLY? IF YES, HOW MANY HOURS A WEEK?

6. HOW MANY MEALS DO YOU EAT EVERYDAY?

HEIGHT (in feet)

WEIGHT (in lbs)

7. DO YOU SLEEP PROPERLY AT NIGHT? IF YES, HOW MANY HOURS DO YOU SLEEP?

8. ARE YOU A VEGETARIAN OR NON VEGETARIAN?

AGE

SINGLE OR MARRIED

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9. DO YOU HAVE ANY WORKOUT EQUIPMENTS AT HOME? IF YES, THEN WHAT KIND OF EQUIPMENTS?

10. DO YOU HAVE A WEIGHT SCALE AT HOME?

Submit

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