Guest Check-in – KalQlate Science Wellness and Fitness, LLC

Personal Information

First Name

Last Name

Address

Today's Date

Birth Date

Your Best Email

Cellphone Number

Permission to text you (used for education, rewards, and incentives for our studio only. Keep in mind if you answer "No", you will miss out on offers and incentives. We promise not to spam you.

Yes

Emergency Contact Name

Emergency Contact Number

Height and Weight

Height Feet

Inches

Weight

Health Questions

1. Have you experienced any chest pain recently? (optional)

Yes

2. Do you experience chest pain while participating in exercise or physical activity? (optional)

Yes

3. Do you lose balance because of dizziness and/or do you ever lose consciousness (optional)

Yes

4. Do you have bone or joint problems that could be worsened by a change in your physical activity? For Example: (back, knee, or hip) (optional)

Yes

5. Is your doctor currently prescribing you medication for blood pressure or heart condition? Example: (water pills) (optional)

Yes

6. Do you know of any reason(s) why you should NOT do physical activity? (optional)

Yes

***Please any and all health problems and explain "Yes" answered questions in detail:

In Your Opinion

1. I have a hard time sticking to my workouts?

Yes

Sometimes

24% (13) | Yes

35% (19) | No

42% (23) | Sometimes

2. I start things that I rarely finish

Agree

Somewhat Agree

Somewhat Disagree

Disagree

5% (3) | Agree

24% (13) | Somewhat Agree

35% (19) | Somewhat Disagree

36% (20) | Disagree

3. What is the main reason you decided to try KalQlate Science? (Select 1-3 main reasons you are interested)

I am extremely busy and I needed a solution that saved me time

I love the science

I like the one to one

I want to improve my current fitness goals I have been working on at other gyms or home gym

I need help gaining muscle

I need help losing weight

7% (7) | I like the one to one

8% (8) | I need help gaining muscle

19% (18) | I am extremely busy and I needed a solution that saved me time

19% (18) | I love the science

22% (21) | I need help losing weight

26% (25) | I want to improve my current fitness goals I have been working on at other gyms or home gym

4. I need extra support with my diet

5. What diets have you tried?

Calorie Restrictive

Keto

Intermittent Fasting

Paleo

Fasting and Detox

High Protein

Vegan

Macronutrient

None

122

5% (6) | Vegan

6% (7) | Macronutrient

7% (8) | None

7% (9) | Fasting and Detox

9% (11) | Paleo

13% (16) | Keto

14% (17) | High Protein

18% (22) | Intermittent Fasting

21% (26) | Calorie Restrictive

122

6. On the sliding scale tell us how happy your are worth your current body.

Completely Unhappy Completely Happy

I have answered everything correctly and to the best of my knowledge

I am aware of the risks in observing or participating in the activities offered and sponsored by KalQlate Science Wellness and Fitness, LLC and I understand that all sports or fitness that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realize that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death. It is understood that KalQlate Science Wellness and Fitness, LLC is responsible for any damage that would be resulting from a fault of KalQlate Science Wellness and Fitness, LLC and its representatives.

I agree to the terms and conditions

Signature

World's Best Fitness Innovation And Smart Fitness Studio

Personal Information

Height and Weight

Health Questions

In Your Opinion