8 Week Ab Fitness & Nutrition Program
8 week healthy body transformation program with Briana Michel. Results may air on a global TV Commercial.
* Required
First & Last Name
*
Your answer
Current Age
*
Your answer
Date of Birth (MM/DD/YY)
*
MM
/
DD
/
YYYY
Phone
*
Your answer
Email (be sure it is typed accurately)
*
Your answer
Height
*
Your answer
Current Weight
*
Your answer
Occupation
*
Your answer
# of Kids and Ages, if any
Your answer
Weight Loss Goals (be specific - ideal weight, size, clearing up of health concerns, improvement of lifestyle, fitness goal, etc)
*
Your answer
List ALL Current Medications & Supplements (type N/A if you do not take anything)
*
Your answer
Do you have any of the following?
*
Type 1 Diabetes
Type 2 Diabetes
Bipolar Disorder
Hypoglycemia/Hyperglycemia
Cancer of any form
Thyroid issues (diagnosed)
Thyroid issues (Suspected, but not diagnosed)
Gut Health issues (constipation, diarrhea, IBS, IBD, Chrohns Disease)
High Blood pressure
Sleep Disorders (Apnea, Inability to fall asleep or stay asleep)
Depression or Anxiety
None of the Above
Other:
Required
Any Current Fitness Regimen? Please describe briefly
Your answer
How would you describe your current eating?
Your answer
Why do you want to participate in a public weight loss transformation? Why change now?
Your answer
Any injuries or physical limitations?
*
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of Briana Michel.
Report Abuse
Forms
