Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone # *Sex *MaleFemaleAge *Please check the category that best describes your fitness goals: *Weight Loss OnlyWeight Loss & ToningWeight Loss & Increased MuscularityMaintenanceWeight GainHow much do you weigh now? *What is your goal weight?What is your approximate height? *Do you know your approximate bodyfat percentage (%) ?YesNoIf Yes, what is it and how was it measured?What is your goal bodyfat percentage (%) ?How many days a week are you currently exercising? *01234567Include both cardiovascular and resistance exercise.Please describe your current weekly exercise routine:Are you currently following any of these mainstream diets?NoWeight WatchersKetoPaleoSouth BeachAtkinsIntermittent FastingJenny CraigNutrisystemsOtherDescribe your current nutrition plan including any dietary habits that you feel currently prevent you from reaching your fitness goals (sweets, late night eating, alcohol, fast foods, etc.): Please list any nutritional supplements you are currently using:Do you have any health problems or physical disabilities? *YesNoIf Yes, please describe or list:Are you currently taking any prescription medication? *YesNoIf yes, please list:Do you currently smoke cigarettes? *YesNoIf Yes, how much?Please include any other information you feel is pertinent to your program participation:How Did You Hear About Tweak My Program?NameSubmit