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CONTACT US
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Quick Application Form
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Age *
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(Inches)
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Current Weight *
Enter in Kilograms.(Example: 125 kgs)
Birthdate *
Best time of day to contact you ? *
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Morning
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Phone Number *
How did you first learn about Shruti Dhall Fitness ? *
---
Referral from Shruti Dhall Staff Member
Referral from Regional Coach
Referral from Shruti Dhall Member
Shruti Dhall Fitness Website
Outdoor Fitness Event
Facebook
YouTube
Fitness Articles
Attended a seminar that featured Shruti Dhall Fitness
Other
When did you learn about Shruti Dhall Fitness ? *
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Within the last 24-48 hours
Within the last week
Within the last several weeks
Within the last 3 months
Within the last 6 months
Over six months ago
Name of the person that referred us?
Do you have social media accounts ? *
---
Yes
No
Facebook Handle (If Yes)
Instagram Handle (If Yes)
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Choose one of the following Shruti Dhall Fitness Programs! *
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Exchange Of Energy
Online Training
Personal Training
What is the most important trait in a Coach that would motivate YOU : *
---
Understanding and Supportive
Straight forward and to the point
I Don't Know
I’m ready to upload my photos now!
I’ll upload my photos later. I understand that I will not receive my customized Shruti Dhall Plan until my photos have been received.
Applicant Photo - Front View
Applicant Photo - Back View
Applicant Photo - Side View
How much time are you willing to commit to your Shruti Dhall Fitness program? *
---
Less than 1 hour/day 5days/week
1 hour/day 5 days/week
1-2 hours/day 5 days/week
3 hours/day 5 days/week
Doesn’t matter
Do you currently do cardio?
---
Yes
No
What type of cardio have you been doing ? *
Running
Cardio Machines
Yoga
Group Exercise Class
Zumba
Bootcamp
At-home Workout Videos
Other, Please specify
On average, how long are your cardio sessions?
On average, how many days per week do you perform cardio?
Do you currently belong to a gym ? *
---
Yes
No
Do you currently lift weights/strength train?
---
Yes
No
What type of strength training have you been doing ? *
Free Weights
Machines
Group Exercise Class
At-home Workout Videos
Other, Please specify
On average, how long are your strength training sessions?
On average, how many days per week do you strength train?
How long have you been training/exercising ? *
---
1-3 years
3-5 years
>5 years
Have you tried other fitness / diet programs before ? *
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Yes
No
Please indicate what types you’ve tried ? *
DVDs
Books
Online Training
Personal Trainer
Fitness Video Games (Xbox, PS3, Wii)
My Own Workout / Diet Plan
Other
Why did other fitness / diet programs NOT work for you ? *
Was not personalized for me
Couldn't stay motivated
Too boring
No support system
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Do you have any PHYSICAN DIAGNOSED health issues ? *
No
High Blood Pressure
High Cholesterol
Digestive Issues
Thyroid Issues
Hernias
Migraines
Anxiety
Depression
Overeater
Eating Disorder
Other
Do you take any type of medications ? *
---
Yes
No
Please list what prescription medications you take. (If Yes)
Medication
Dosage (mg)
How often (daily)
Do you have any injuries that may negatively impact your training ? *
No
Neck
Shoulder
Wrist
Arm
Back
Knee
Ankle
Hip
Other
Are you UNABLE to do any of the following ? *
CAN DO ALL
Running
Jumping
Lunging
Non-weighted
Squats
Other
Do you have any PHYSICIAN DIAGNOSED food allergies ? *
No Food Allergies
Celiac (Coeliac) Disease
Seafood
Shellfish
Eggs
Other
Are you a Vegetarian or Vegan ? *
---
Vegetarian
Vegan
Neither
Do you have MANDATORY dietary restrictions ? *
---
Yes
no
How would you categorize your feelings about FOOD ? *
Eat to Live
Live to Eat
Eat more when relaxed & happy
Eat more when depressed or stressed
Eat more when bored or lonely
Like / Love cooking
Dislike / Don't Know Cooking
Do you currently track your caloric intake daily ? *
---
Yes
No
How many meals per day do you eat ? *
---
1 or 2
2
3
4
5
6
7+
Do you currently take any kinds of supplements ? *
---
Yes
No
Please list what supplements you take. (If Yes)
Supplement
Dosage (mg)
How often (daily)
Please share your current lifestyle (meals with timing) *
What is your Goal *
Any other information you think i should know? *
Confirm you have read and understand the Shruti Dhall Fitness™ Programs & Pricing Options *
Yes, I have read and understood the Shruti Dhall Fitness™ Programs & Pricing Options
HOME
ABOUT US
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Exchange Of Energy
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