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First Name:
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Last Name:
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Email Address:
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Phone Number:
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Address:
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City:
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Province:
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When was the last time you exercised?
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What did you do and for how long?
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What if any would you like to change about your physical state?
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What is your current weight, height & age?
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Where do you think you need the most help?
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What if any diet have you tried?
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What's your occupation and is it stressful?
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What are your alcohol, caffiene and cigarette habits?
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How much sleep do you get?
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Any Heart problems or medical issues?
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What medication or supplements are you taking?
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Is there any reason you cannot exercise vigorously?
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Describe what you eat in a typical day.
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How did you hear about us?
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What time & date would you like to attend?
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I agree that all of the above information is true.
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Yes
