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AzraKhanFitness Enrollment Form
Please fill this form to help us get a better understanding of your needs. So we can provide you better and more personalized services.
Eat wise Drop a size.
Azra Khan Fitness
* Indicates required question
Email
*
Your email
Contact Number
*
Your answer
Full Name
*
Your answer
Age
*
Your answer
Gender:
*
Male
Female
Other:
Weight
*
Your answer
Height:
*
Your answer
Place of Residence/Country
*
Your answer
Medical Issues
*
PCOD
Diabetes
Thyroid
vitamin D deficiency
Lactose intolerance
Prediabetic
Post pregnancy
Endometriosis
Menopause
None
Other:
Required
WHICH PROGRAM YOU WANT TO CHOOSE
*
4 WEEK
8 WEEK
12 WEEK
ONE TIME CONSULTANCE
MAINTENCE
Required
What are the challenges you are facing in respect to weight loss (*elaborate on what is most difficult for you)
Your answer
What is your BIGGEST short term goals? (What matters MOST to you right now?)
Your answer
What is your BIGGEST long term goals?
Your answer
How your weight affects your mind/ will losing weight help you with your self esteem(*elaborate)
Your answer
On a scale of 1 to 5, how motivated are you to work towards your fat loss goals? (1 = not motivated, 5 = highly motivated)
1
2
3
4
5
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Have you lost weight in the past? If so, WHAT DID YOU DO, HOW MUCH WEIGHT DID YOU LOSE & HOW LONG AGO? Please elaborate. *
Your answer
What do you expect from me as your nutritionist ?
Your answer
I love getting to know our clients. Please share some information about yourself with us.
Your answer
A copy of your responses will be emailed to the address you provided.
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