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Registration Form
How did you hear about us?
Do you have any concerns/questions about the program?
Name
Address
City and State
Zip Code
Home Phone Number
Work Phone Number
Cell Phone Number
E-Mail
Best time and way to contact you?
Date of Birth
Height
'
"
Weight
Brief Medical History (Help us to help you by answering the following:)
Are you currently under a Physicians Care?
Please Select
Yes
No
Do you have any of the following? Check all that apply.
Heart Condition
Heart Disease
High Blood Pressure
Diabetes
Depression
High Cholesterol
Other
Please elaborate on any conditions selected above
Are you taking any prescription medications?
If so, please specify what.
Did you notice weight gain after using these medications?
Please Select
Yes
No
Do you smoke?
Please Select
Yes
No
Do you drink alcohol?
Please Select
Yes
No
Do you drink regular or diet sodas?
Please Select
Regular
Diet
Both
Do you drink regular (caffeinated) coffee?
Please Select
Yes
No
Other caffeine drinks?
Please Select
Yes
No
Do you take any nutritional supplements?
Please Select
Yes
No
If yes, please specify
Do you have any chronic pain or current injuries?
Please Select
Yes
No
If yes, please specify
Do you have any other health information we
should be aware of?
What Diets/Weight Loss Programs have you
tried in the past?
What do you wish to accomplish by enrolling
in our 12 week program?
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Phone: 203-230-0543 E-mail:ppulisciano@snet.net
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