AzraKhanFitness Enrollment Form
Please fill this form to help us get a better understanding of your needs. So we can provide you better and more personalized services.

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Azra Khan Fitness
Email *
Contact Number *
Full Name *
Age *
Gender: *
Weight *
Height: *
Place of Residence/Country *
Medical Issues *
What are the challenges you are facing in respect to weight loss (*elaborate on what is most difficult for you)
What is your BIGGEST short term goals? (What matters MOST to you right now?)
What is your BIGGEST long term goals?
How your weight affects your mind/ will losing weight help you with your self esteem(*elaborate)
On a scale of 1 to 5, how motivated are you to work towards your fat loss goals? (1 = not motivated, 5 = highly motivated)
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Have you lost weight in the past? If so, WHAT DID YOU DO, HOW MUCH WEIGHT DID YOU LOSE & HOW LONG AGO? Please elaborate. *
What do you expect from me as your nutritionist ?
I love getting to know our clients. Please share some information about yourself with us.
A copy of your responses will be emailed to the address you provided.
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