Health Questionnaire Fill out the below health questionnaire. This gives us an idea of your health and allows us to access your starting point. Name First Last Date Date Format: MM slash DD slash YYYY PhoneEmail How did you hear about the Balanced Habits KICK START?*What is your MAIN GOAL by participating in the KICK START?*How many MEALS do you currently consume on average per day?*How many SNACKS do you currently consume on average per day?*How often do you do cardiovascular exercise per week?What is the duration?*How often do you do strength train per week?*What is the duration?*Do you do any other forms of exercise?*YesNoIf yes, what?Are you currently under the care of a Physician?*YesNoIf yes, why?Are you currently taking any medications?*YesNoIf yes, please list them and how long you have been taking them:Have you been diagnosed as Diabetic?*YesNoIf yes, what type:Pre-diabeticType IType IIIf yes, what medications and frequency do you take:Have you had any form of Bariatric Surgery?*YesNoIf yes, what type:If yes, when was the surgery performed?If yes, approximately how many ounces of food can you ingest per sitting?Have you ever dealt with an eating disorder that we should be made aware of?*YesNoIf yes, please explain:Are you currently lactating?*YesNoIf yes, on average how many times per day?Are you a Vegan?*YesNoDo you have Celiac Disease or a high Gluten Sensitivity?*YesNoYour MeasurmentsPlease be sure you watch the below video on how to accurately take your measurements.Age*Gender*MaleFemaleHeight*Weight*Abdomen*Hip (women only)Wrist (men only)Upper R / L Arm*Upper R / L Leg*R / L Calf*Upload your images Drop files here or Accepted file types: jpg, png. Upload up to 3 images of yourself. Photos will not be shared (unless given permission). It is highly recommended to submit photos though as your final report will have Pre & Post KICK START photos! Needed photos: Full front view & both side views Suggestions for the photos: - Wear clothing that reveals the body contour. Women can wear sports bra/tank top & shorts/leggings and men can wear no top/tank top & shorts. - Take in a well-lit area, preferably with more natural lightIs there anything you'd like to disclose that we need to know to support you to be successful during the 28-Day program that we have not asked?Agreement* Select All Yes, I have disclosed all necessary information that the Balanced Habits KICK START Team needs to know about me. Yes, I understand what is expected of me during this 28-Day program and commit to the suggestions and guidelines. Yes, I will attend the weekly journal review, follow the journal requirements, do the suggested amount of exercise. Yes, I will read the emails coming from my Food Coach I promise to not expect perfection, but I do expect improvement due to my efforts. Name* First Last EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.