Home - Super Wellness and Lifestyle

First Name *

Last Name *

Date Of Birth *

Email *

Weight In Kg *

Height In Feet *

Waist In Inches *

Fitness Goal *

Fitness Level *

What diet are you following right now ? Describe in detail your current eating habits. *

What is your current/previous exercise routine ? *

Are you taking any over the counter or prescription medications or drugs ? If Yes, Please list it *

Any Heart Condition ? If Yes, Please explain. *

Any Pain in the chest when you do a physical activity ?

Any Pain in the chest when you were not doing any physical activity ?

Do you lose your balance of dizziness or do you ever lose consciouseness ?

Do you have a bone or joint problem that could be made worse by a change in your physical activity ?

Is your doctor currently prescribing drugs for blood pressure or heart condition ?

Do you know of any other reason why you should not do physical activity ? *

Smoking

Alcohol

Any Medicine (If Yes, Please explain) ? *

Any Surgery in past 12 Months (If Yes, Please explain) ? *

Any pre existing injury or physical restrictions that may limit your ability to exercise (If Yes, Please explain) ? *