Name (First and Last)

Email

Birthday

Age

Gender

Height

Weight

Goal Weight

Current Daily Activity (please be as detailed as possible regarding activities, exercise regimen and length of time)

Please list any barriers or successes in weight loss and/or fitness

Please list any medical conditions or regular medications.

List a food/food group you have learned you cannot live without.

What is your “why” for joining this program? Be detailed and specific.

Agreement Agreement By completing this questionnaire, you agree that you have received permission from your doctor prior to signing up. You also agree that the information provided to you is not an individual prescription, but is education intended to enhance your knowledge of health as it relates to nutrition and physical activity. You understand that the wellness information received will not take medications, food allergies, or other illnesses into consideration and that you are responsible for the management of such. Perfect Fit Nutrition will not be held responsible for any injury or illness that may occur during or after this membership term.