Weight Loss Questionnaire

Personal Information

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Full Name: *

Email *

Age: *

Height (cm): *

Current Weight (kg): *

Target Weight (kg) in 12 weeks:

T-Shirt Size:SMLXLXXLXXXL

Do you have any medical conditions or injuries that could impact your training? (Please explain) *

Are you currently taking any medications or supplements? *

How many days per week do you currently exercise? (0-1, 2-3, 4-5, 6+)

• 0
• 1
• 2
• 3
• 4
• 5
• 6
• 7

What type of exercise do you primarily engage in? (Strength training, cardio, sports, etc.)

On a scale of 1-10, how would you rate your physical fitness?

Why do you want to lose 10kg in 12 weeks? (Be specific)

What challenges have prevented you from achieving your fitness goals in the past?

On a scale of 1-10, how committed are you to making the necessary lifestyle changes?

Do you have a support system (family, friends) to encourage you during this program?

Are you willing to send daily or weekly progress photos and updates? (Yes/No)

• Yes
• No

How do you prefer to be held accountable? (Check-ins, group chat, personal reminders)

What will success look like for you at the end of 12 weeks?

Do you consent to following the provided exercise and meal plans, understanding the disclaimer and personal responsibility involved? (Yes/No) *

• Yes
• No

Submit

Disclaimer:
The information provided on Manjutsu’s Weight Loss and Fitness Program, including but not limited to advice, guidelines, and recommendations, is based on personal experience and individual perspectives. It is essential to acknowledge that results may vary among individuals, and the program’s effectiveness is not guaranteed for everyone.

Before commencing any fitness or weight loss program, it is strongly advised to consult with a qualified healthcare professional or fitness expert, especially if you have pre-existing health conditions or concerns. The advice offered is not a substitute for professional medical guidance, diagnosis, or treatment.

Manjutsu and its representatives disclaim any liability arising from the use or application of the information provided. Users should take full responsibility for their actions, choices, and interpretations of the guidance offered within this program. Any decisions made based on the information provided are at the user’s own risk.
It is imperative to recognize that each individual’s body and health status are unique, and what may be effective for one person may not be suitable for another. Manjutsu does not assume responsibility for any adverse reactions, injuries, or consequences resulting from the implementation of the program.

By participating in Manjutsu’s Weight Loss and Fitness Program, users acknowledge and agree to release Manjutsu and its affiliates from any claims, damages, or liabilities arising out of or in connection with the use of the program.

Ultimately, users are encouraged to make informed decisions about their health and well-being, and to seek professional advice when needed. ManJutsu is here to support you on your fitness journey, but individual results may vary.