Intake Form – Employee Wellness Australia

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Intake Form

2.0 Intake Form

"*" indicates required fields

Step 1 of 3

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First name*

Last name*

Email*

Please use the exact email you entered when signing up

Date of birth*

DD slash MM slash YYYY

Age

Gender*

Male

Female

Preferred unit of measurement*

Metric (kg, cm)

Imperial (lbs, in)

Weight (lbs)*

Weight (kg)*

Height (in)*

Height (cm)*

Primary goal*

Lose weight

Gain muscle

General fitness

At home

Level of training experience*

Beginner

Intermediate

Advanced

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Equipment access*

Full gym

Bodyweight

Dumbbells

Bands

Kettlebells

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How many days per week would like to workout?*

1

2

3

4

5

6

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Current injuries*

Lower back

Shoulder

Hips

Knees

None of the above

Daily activity level*

Sedentary

Lightly active

Moderately active

Very active

Dietary preference*

No Preferences

Vegan

Vegetarian with eggs

Vegetarian with dairy

Vegetarian with eggs and dairy

Pescatarian

Paleo

Select any foods you would like to avoid

fish

shellfish

eggs

dairy

soy

gluten

treeNuts

peanuts

meat

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What habit(s) would you like to work on?*

SELECT UP TO THREE

Eat protein

Eat good fats

Eat complex carbs

Eat vegetables

Follow portion guides

Practice eating slowly

Eat until 80% full

Prepare your own meals

Drink only zero-calorie drinks

Abstain from alcohol

Take a more active route

Make it easier to work out

Do an enjoyable activity

Recruit social support

Reward yourself after a workout

Prioritize self-care

Celebrate your wins

Digital detox before bed

Practice a bedtime ritual

Creating A Happy & Productive Workforce

Contact Us

info@employeewellnessaustralia.com.au
0434 104 116

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