Questionnaire

If you would like to speak with Mahmood or a member of our staff direct please call us at 407-654-3848.

Indicates a Required Field

Name:
Address:
City:
State:		AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
Postal Code:
Phone:
Email:
Preferred Contact Method:		Email Phone
Age:
Sex:		SelectMaleFemale
Height:
Present Weight:
Desired Weight:
Describe your exercise program:		Select None Beginner Intermediate Advanced
How often do you exercise?		Select None 1 2 3 4 5 6 7
How long are your workouts?		Select 15 minutes 30 minutes 45 minutes 1 hour Over An Hour

In what sports or physical activities do you regularly participate?
What do you eat during the course of an average day? Please include both meals and snacks.
How many 12 oz glasses of water do you drink in an average day?		Select None 1 2 3 4 5 6 7 8 9 10
What kind of vitamins and supplements do you take?
If you know it, fill in your body fat percentage.
Do you have any physical limitations?		Select Yes No
Are you taking any prescription medications?		Select Yes No
Rank the importance of the following objectives:
Lose Fat... and Inches:		Select 1 2 3 4 5 6 7 8 9 10
Improve Athletic Performance:		Select 1 2 3 4 5 6 7 8 9 10
Get Healthier and Feel Better:		Select 1 2 3 4 5 6 7 8 9 10
Build Strength and Muscle Mass:		Select 1 2 3 4 5 6 7 8 9 10
I have read the "Terms and Conditions" and accept them as written.

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