LIVVY CHOO FITNESS
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Michaelangelo Bance
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Weight Loss Champs Podcast
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On-Demand Workout
Senior Women On-boarding
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Name
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First
Last
What age group do you fall in
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18 -25
26 -35
36 - 44
45 -50
51 -56
57 - 60
60+
Health Questionnaire
Medical History (Please Check All That Apply To You)
*
Have you ever been hospitalized for heart issues
Have you ever been hospitalized for broken bones
Have you ever been hospitalized for back issues
Have you ever had arthritis or joint pain
Have you ever had hepatitis
Do you have asthma
Do you have food Allergies
Have you ever had a head injury
Are you on any medication? If so please list.
*
Fitness Goals
What is your fitness goal
*
Lose Weight
Tone Body
Increase Stamina/Energy
Increase Strength/Power
Sculp Body for Upcoming Event
Before Picture
(Optional)
Front Picture
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Max file size: 20MB
Side Picture
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Max file size: 20MB
Back Picture
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Max file size: 20MB
Submit
Home
Michaelangelo Bance
Testimonials
Weight Loss Champs Podcast
Contact Us
On-Demand Workout
Senior Women On-boarding