Omron checkin Form

OMRON Form

Check-In

Berry Fit OMRON Checkin

First Name

Middle Name

Last Name

Coach / Instructor Name

Address

Street Name

Building / Block Number

Zip Code

Country

Occupation

Phone/Mobile

Gender

Male

Female

Other

Date of Birth

Age

Weight (kg)

BMI

Weight to Lose (kg)

Ideal Weight (kg)

Body Fat (%)

Visceral Fat Rating

Skeletal Muscle Mass (kg)

Basal Metabolic Rate

Metabolic / Body Age

Body Health Lifestyle Analysis

What are your health goals and what do you want to achieve?

What methods have you tried before to achieve your health goals

Why do you want to make a change now to ensure you achieve your health goals

What do you eat for your breakfast, lunch, dinner and supper? Any snacking habit? How much do you spend on each meal?

Do you eat fruits and vegetables daily?

Yes

How much water do you drink a day (Cups / Litres)

How often do you exercise? (Times / Day & Minutes / Day)

Do you have gastric or consitpation problems? How serious is it?

Are you on any medication (long term)? What are the medications for?

Do you have any health issues? Joint pain, backache, migraine, menses cramp etc

3/4 Body front view

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3/4 Body right side view

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Close up face view

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Coach / Instructor Remarks

Customer Signature

Coach Signature

By submitting you consent to have Berry Fit store my submitted information so they can respond to your inquiry

Tampines Outdoors

Tampines Sun Plaza Park

Tampines Avenue 7

Singapore 529621

Studio - Tampines Retail Park

1 Tampines North Dr. 1

T-Space 09-05

Singapore 528559

Hougang Outdoors

Hougang Harmony Park

646 Upper Serangoon Road Block 464

Singapore 530464

Email

berryfitclubs@gmail.com

UEN #

202545964M