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Enrollment Form
Let us get to know you a little better
Personal Information
First name*
Last name*
Email*
Phone number
City
Country
Age*
Gender*
Select one
Male
Female
Other
Physical Fitness Section
Weight (in pounds)*
Height (in cm)*
Rate your current physical condition as below - (On the scale 1 to 10)
Muscular Strength
Select one...
1
2
3
4
5
6
7
8
9
10
Muscular Endurance
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1
2
3
4
5
6
7
8
9
10
Cardiovascular Endurance
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1
2
3
4
5
6
7
8
9
10
Flexibility
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1
2
3
4
5
6
7
8
9
10
Joint mobility
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1
2
3
4
5
6
7
8
9
10
Postural Issue
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1
2
3
4
5
6
7
8
9
10
Obesity
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1
2
3
4
5
6
7
8
9
10
High Fat storage areas in body
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Arms
Abdominal
Thighs
How would you describe your job?
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Desk Job
Involves only walking
Physically demanding
How would you describe your exercise experience level?
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Beginner
Intermediate
Advanced
How would you describe your overall activity level?
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Very low
Sedentary
Very high
Mental Fitness Section
Have you ever had or currently have issues such as anxiety, depression or stress?
Select one...
Yes
No
Do you ever find it difficult to focus or concentrate on your work? Or keep yourself calm or control your anger in certain situations?
Select one...
Yes
No
How many hours of uninterrupted sleep you have?
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1 to 3 hours
3 to 5 hours
More than 5 hours
Rate your overall Stress level (on scale of 1-10)
Nutrition Section
What are your food preferences?
Select one...
Vegetarian
Eggetarian
Non - Vegetarian
Currently, How many meals you have in a day?
What do your meals include?
How would you rate your eating habits?
Select one...
Not healthy
Somewhat Healthy
Healthy
Do you Smoke? - If yes, How many times a day?
Do you consume alcohol? - If yes, How many times a week?
Have you followed any Fad diets in past or currently following?
Medical Section
Do you have any medical condition? Please select.
Select one...
None
Diabetes/Pre-diabetic
High/Low blood pressure
Thyroid/Hypothyroid
PCOD/PCOS
Asthama/Respiratory ailments
Cervical/Back pain/Neck pain
Migrain/Frequent Headaches
Other
Do you have any food allergies?
Are you pregnant currently or given birth within last 6 months?
Select one...
Yes
No
I am a male
Have you had any surgeries, Injuries or fractures within last 6 months?
Program Details
After 12 weeks, I want to see myself as -
What do you feel about our consultation service and enrollment process?
What do you type in google search or youtube while looking for health programs?
How did you find us?
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Instagram
Google
Word of Mouth
Which program are you interested in?*
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12 Weeks Online 1-1 Coaching - 35000 INR
12 Weeks Online Group Coaching - 15000 INR
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