Consultation – AskDamz

Details About You

Your Name*

Title First Name Last Name

Gender*

Male

Female

Date of Birth*

Age*

Phone Number*

Your Email Address*

Instagram Handle

Preferred Mode of Communication*

Text Message

Phone Call

Your Delivery Address*

Occupation*

No. of Children

Marital Status*

Height*

BMI

Current Weight*

Target Weight*

Bust*

Waist*

Hip*

Dress Size*

Top Size*

Trouser Size*

Emergency Contact

Full Name*

First Name Last Name

Relationship*

Email Address*

Phone Number*

Home Address*

Your Goals

Proposed Start Date

Main Purpose for Wanting a Healthier Lifestyle:*

Primary Area of Focus

Preferred Coaching Period*

Have you had any previous experience in the following?

Personal Training*

Yes

Gym Membership*

Yes

Dietician*

Yes

Weight Loss Program*

Yes

What was your last experience like?*

Complete this sentence*

Is there any aspect of this program that you will like to omit OR that may raise any concern(s)?*

(If yes, please explain)

Your Current Lifestyle

In your own words, describe yourself*

In your own words, describe your diet*

How would you describe your daily meal pattern?*

1 meal a day

2 meals a day

3 meals a day

More than 3 meals

How would you describe your daily snack pattern?*

I don’t snack

1 snack a day

2 snacks a day

More than 2 snacks a day

Other

How many litres of waters do you drink daily?*

Less than 1 Litre a day

1-2 Litres a day

More than 2 Litres

How often do you drink alcoholic drinks?*

Never

Once a month

2-4 times a month

2-3 times a week

4 or more times a week

On average, how many hours of sleep do you get daily?*

Below 5 hours

Between 5-7 hours

Between 7 - 9 hours

Above 9 hours

How would you describe your level of stress?*

Low

Medium

High

How often do you smoke?*

Never

Occasionally

Regularly

Chain Smoker

What is your Bowel movement like?*

Daily

Twice a week

3-4 times a week

Irregular

How often do you take nutritional supplements?*

Never

Daily

Weekly

Monthly

How often do you exercise?*

Your Medical History

Doctor’s Name

Phone Number

Hospital Address:

Do you take any medication?*

Yes

If you take medication, please describe what it is for.*

Do you have any skin condition?*

Yes

Are you currently Breastfeeding?*

Yes

Do you have any allergies?*

Yes

Have you had any surgical operation?*

Yes

General Food List

List Your Food Likes

List Your Food Dislikes

What Snacks Do You Like

What Snacks Do You Not Like

Consultation Form

Details About You

Emergency Contact

Your Goals

Your Current Lifestyle

Your Medical History

General Food List