Your Name:

Address:

Phone:

Cell Phone:

E-Mail:

Occupation:


Do you have any children
Yes
No

If so, what are their ages?

What are you purchasing?
(if unsure, go to my
fitness shop to view options)

Complete this section within
24 hours of your answers:
Measure & report the following,
if you have a tape measure:

What would you like to achieve with Michellefitness.com related to health,
fitness or weight loss? Briefly describe.

Describe typical meals and times
you eat for the following:

Do you eat out a lot? If so, what and where?

List two of your favorite options for:

Are you open to using protein shakes, bars, vitamins, herbs or other supplements recommended for your success?

Yes
No

If no, explain your concerns. Not to include anything that is not over the counter and FDA approved.

How much water do you drink per day?

How many times a week do you exercise?

Briefly describe what you do for exercise?

Are you a pageant or fitness competitor?
Yes
No

If yes, what is your next contest and when?

Are you currently on any medication or prescription pills of ANY KIND?
Yes
No
If so what specific medication?


Do you have any limitations of the KNEES, BACK, WRISTS, SHOULDERS, NECK or other? If so, please explain:
Be sure to mention slipped disks and surgeries in the last year.

Do you have any problems with BALANCE that are related to health or aging?
Yes
No
If so, please explain:

Are there any exercises you can not, or do not enjoy doing?

Are you open to? (select)

Do you suffer from or have a diagnosed mental problem or anything related to stress or anxiety, panic attacks?
Yes
No

Do you have fibromyalgia or chronic fatigue syndrome?
yes no

If yes, briefly describe your conditions an obstacles related to this condition.

Do you have a heart condition or high/low blood pressure? Any other health issues?
Yes
No

Specify Conditions:

Have you in the past year or will you have surgery?
yes no

Do you have any issues related to addiction to food, alcohol, cigarettes or drugs. Please describe and add any goals you have related to this.

If you have a full body photo of you now,
please attach one to an email .
Front and back are ideal and send to
synergystics@aol.com.