QUICK APPLICATION FORM

Payment Id *

First Name *

Last Name *

Email *

Confirm Email *

Address *

Street Address *

City *

State / Province / Region *

ZIP / Postal Code *

Country *

Age *

Height (Feet)

(Inches)

Current Weight *Enter in Kilograms.(Example: 125 kgs)

Birthdate *

Best time of day to contact you ? *

Phone Number *

How did you first learn about Shruti Dhall Fitness ? *

When did you learn about Shruti Dhall Fitness ? *

Name of the person that referred us?

Do you have social media accounts ? *

Facebook Handle (If Yes)

Instagram Handle (If Yes)

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Choose one of the following Shruti Dhall Fitness Programs! *

What is the most important trait in a Coach that would motivate YOU : *

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? *

Do you currently do cardio?

What type of cardio have you been doing ? *

RunningCardio MachinesYogaGroup Exercise ClassZumbaBootcampAt-home Workout VideosOther, 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 ? *

Do you currently lift weights/strength train?

What type of strength training have you been doing ? *

Free WeightsMachinesGroup Exercise ClassAt-home Workout VideosOther, 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 ? *

Have you tried other fitness / diet programs before ? *

Please indicate what types you’ve tried ? *

DVDsBooksOnline TrainingPersonal TrainerFitness Video Games (Xbox, PS3, Wii)My Own Workout / Diet PlanOther

Why did other fitness / diet programs NOT work for you ? *

Was not personalized for meCouldn't stay motivatedToo boringNo support system

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Do you have any PHYSICAN DIAGNOSED health issues ? *

NoHigh Blood PressureHigh CholesterolDigestive IssuesThyroid IssuesHerniasMigrainesAnxietyDepressionOvereaterEating DisorderOther

Do you take any type of medications ? *

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 ? *

NoNeckShoulderWristArmBackKneeAnkleHipOther

Are you UNABLE to do any of the following ? *

CAN DO ALLRunningJumpingLungingNon-weightedSquatsOther

Do you have any PHYSICIAN DIAGNOSED food allergies ? *

No Food AllergiesCeliac (Coeliac) DiseaseSeafoodShellfishEggsOther

Are you a Vegetarian or Vegan ? *

Do you have MANDATORY dietary restrictions ? *

How would you categorize your feelings about FOOD ? *

Eat to LiveLive to EatEat more when relaxed & happyEat more when depressed or stressedEat more when bored or lonelyLike / Love cookingDislike / Don't Know Cooking

Do you currently track your caloric intake daily ? *

How many meals per day do you eat ? *

Do you currently take any kinds of supplements ? *

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

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