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Health Questionnaire Form
Step
1
of
3
- Basic Info
33%
Name
(Required)
First
Last
Email
(Required)
Date Of Birth
(Required)
DD slash MM slash YYYY
Gender
(Required)
Male
Female
What's your Instagram handle?
Fitness Goals
What are your main fitness goals? (Select multiple)
(Required)
Fat Loss
Muscle Gain
Strength Gain
Improve Endurance
Increase Flexibility
Improve Cardiovascular Health
Enhance Athletic Performance
General Fitness & Well-being
Postpartum Fitness
Body Recomposition (lose fat, gain strength & muscle and get visible abs)
What are some other health goals you have? (select multiple)
(Required)
Improve Sleep Quality
Increase Energy Levels
Reduce Stress
Improve Digestion
Manage Chronic Conditions (e.g., diabetes, hypertension, thyroid, PCOS,fatty liver, Uric acid levels)
Mental Clarity and Focus
Enhance Mobility & Flexibility
What is your activity level?
(Required)
Sedentary : Little to no exercise, mostly sitting
Lightly Active : Light exercise or sports 1-3 days/week
Moderately Active : Moderate exercise or sports 3-5 days/week
Very Active : Hard exercise or sports 6-7 days/week
Super Active : Very hard exercise, physical job, or training twice a day
Workout preferences
(Required)
Strength Training
High-Intensity Interval Training (HIIT)
Cardio Workouts
Yoga/Pilates
Functional Training
Mobility Workouts
Powerlifting
Plyometrics
Bodyweight Training
Circuit Training
Others
What is your precise current weight? (As of today on an empty stomach) in kgs
(Required)
What is your ideal long term weight goal? in kgs
(Required)
How fast do you want to reach your goal? (approx. months)
Height in cms
(Required)
Waist in cms?
What is your approx. Body fat %?
(Required)
0-5
5-10
10-15
15-20
20-25
25-30
30-35
35-40
40-45
45-50
Shoulders in cms?
Hips in cms?
Neck in cms?
Do you have any dietary preferences or restrictions? (Select all that apply)
(Required)
Vegetarian
Vegan
Pescatarian
Gluten-Free
Dairy-Free
Keto
Eggetarian
No restrictions
Do you have any food allergies ?
(Required)
What are your favourite foods ?
What are your least favourite foods or foods you avoid ?
Do you smoke?
(Required)
Yes
No
Do you consume alcohol?
(Required)
Yes
No
Upload your blood tests if available :
Max. file size: 50 MB.
(Please upload an image of your blood work six months from now, which includes CBC, vitamin D, vitamin B12, lipid profile, renal profile, HbA1c, and thyroid profile.)
Please upload any current prescriptions you have :
Do you have any injuries, surgeries, or medical conditions that we should be aware of?
(Required)
Hidden
Please Upload your Current Progress Pictures (front, side and back with reference image)
Drop files here or
Select files
Max. file size: 50 MB, Max. files: 3.
Please Upload your current Progress Pictures (front, side and back with reference image)
Front Image
Max. file size: 50 MB.
Side Image
Max. file size: 50 MB.
Back Image
Max. file size: 50 MB.
Mental & Emotional Health
How would you rate your current stress level ?
(Required)
Low
Moderate
High
Very High
How offten do you have episodes of emotional eating or binge eating ?
(Required)
Rarely
Occasionally
Often
Almost Always
What are your primary sources of stress? (Select all that apply)
(Required)
Work
Family
Financial
Health
Social Life
What do you do to manage stress? (Select all that apply)
(Required)
Exercise
Meditation
Yoga
Hobbies
Spending time with loved ones
Professional Help (Therapy, Counseling)
Nothing
How would you rate your overall mood and mental well-being ?
(Required)
Excellent
Good
Fair
Poor
How do you feel about your current body image ?
(Required)
Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
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