Health Consultation Form
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Quantum Analyzer with David Lee.
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8-1168 Belanger Ave,
Ottawa, On, K1H 8A2
613.612.4372
info@vitalhealthlife.com
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Personal Information
Name
Email
Address
Trainer
Select Trainer
Askar Shomayev
David Lee
Luz Campos ( Lucky Campos)
Richard Ouellette
Contact
Work
Age
Weight
How often do you participate in physical activities?
What activities are you currently involved in?
Height
Referred By
What health and fitness benefits would you most like to accomplish?
Sport Specific Training
Trim, Firm and Define
Increase Energy
Gain Weight
Reduce Health Risks
Overcome Chronic Health Issues
Lose Weight
Maintain Shape
Reduce Tension and Stress
Increase Flexibility
Reduce Pain
Increase Strength
Gain muscle
Other
Do you suffer from any of the following in the present? Have you had any of these ailments in the past?
Arthritis
Respiratory (Asthma, sinus, etc)
Depression
Digestive Problems
Osteoporosis
Heart Disease
High or Low Blood Pressure
Weight Problems
Allergies
Diabetes
Pain or stiffness in:
Back
Knees
Neck
Shoulders
Other health issues not on the list
List in order of priority which health and fitness goals you would most like to achieve. Rate their importance on a scale of 1-10.
Goal 1
Rating
Rating
1
2
3
4
5
6
7
8
9
10
Time Frame
Goal 2
Rating
Rating
1
2
3
4
5
6
7
8
9
10
Time Frame
Goal 3
Rating
Rating
1
2
3
4
5
6
7
8
9
10
Time Frame
What can Vital Health do to help you reach your goals?
Become Healthier
Motivation
Advance Plateaus
Weight-Loss
Organize Workouts
Lifestyle Modification
Post-Rehab
Nutritional Counselling
Muscular Development
Other
What is your 'WHY' for wanting to achieve these
goals?
Who are the people in your life that will give you support in this healthy lifestyle change?
What additional support and motivation would you like to receive
from me?
If you could be guaranteed to achieve these specific results, how many sessions could you commit to each week or every two weeks?
Submit Now
Schedule a free call with David Lee
Free Consultation on phone with certified fitness and nutrition specialist
Please fill in your information for us to contact you.
Select Preferred Time
Morning (8:00am-12:00pm)
Afternoon (12:00pm-4:00pm)
Evening (4:00pm-9:00pm)
Submit
This will be phone conversation where we call you to discuss your health issues and challenges.
