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Initial Intake
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Initial Intake
Initial Intake
pmirda
2019-12-04T18:32:57+00:00
Welcome to
The Optimal You
Please complete the following intake
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General Information
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Step
1
of 4
Email
*
Name
*
First
Last
Next
Sex
*
Male
Female
Date of Birth (dd/mm/yyyy)
*
Height (ft)
*
Weight (lbs)
*
Goal Weight (lbs)
*
What are your main goals with this program?
*
Lose excess body weight
Tone and tighten up
Gain muscle
Contest prep
General wellness
Improve Digestion
Rate your current activity level.
*
I have little or no activity
I often go for walks
I exercise 1-2 times per week
I exercise 3-5 times per week
I exercise 6-7 times per week
Rate your experience level working out.
*
Beginner (comfortable with machines and resistance bands only)
Intermediate (comfortable with basic free weight exercises)
Advanced (comfortable doing all free weight exercises)
Are there any exercises you cannot perform? Be specific.
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Next
Do you have any special dietary needs?
*
Vegetarian
Vegan
Kosher
None
Please list foods you are allergic/dislike and do not want included in your meal plan.
How many times per week do you want to meal prep?
*
I do not want to cook
1x/week
2x/week
Daily
How often do you eat breakfast?
*
I do not eat breakfast
1-2 days/week
3-4 days/week
5-6 days/week
I eat breakfast every day
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Next
How many cups (250ml or 8oz) of fruit juice or soda do you drink each day?
*
I do not drink sugary drinks
1 cup
2 cups
3 cups
≥4 cups
How many cups (250ml or 8oz) of water do you drink each day?
*
≤1 cup
2-3 cups
4-5 cups
6-7 cups
≥8 cups
How much sleep do you get each night?
*
≤5 hours
6 hours
7 hours
8 hours
≥9 hours
Where did you hear about us?
Sign-up to our newsletter?
Sign-up to our newsletter?
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Phone
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