Xpress Assessment

Date*

First Name:*

Last Name:*

Email:*

A copy of this form will be sent to this email address.

Phone:*

Street Address:

City:

State /Province/Region:

Zip/Postal Code:

Date of Birth:*

Gender:

Height (feet)

Height (inches)

MEDICAL HISTORY:

If NO MEDICAL CONDITIONS, please check the box below:

BODY COMPOSITION GOAL:

MENU PREFERENCES:

CURRENT ACTIVITY LEVEL:

Current Weight (lbs):

Body-Fat % (blank if unknown):

BMR (calories) (blank if unknown):

Neck:

Shoulders:

Chest:

Biceps:

Forearms:

Waist:

Hips:

Thighs:

Calves:

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