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Custom Workout/Diet Plan
Tailored to your individual needs by Vilma Caez

Are you having problems making gains with your current workout and diet program? If you need help, I can surely assist you by developing a customized workout and diet program especially for you.

By completing the form below, I will have enough information to start working on your training routine. I may request a recent photograph

When completing the form, please be thorough. The more information you give me, the higher the quality of the program I create for you. The price is US$125.00. You will receive your customized workout by Federal Express.

1. Contact Information/Billing Address

Name:
Address:
City:
State:

ZIP:

Email Address:
Phone:
Time to Call:

2. Sex

Male         Female

3. Age/Weight/Height/Measurements (at the widest girth of body part)

Age:

Weight:

Height

 

Waist:
Arms:
Chest:
Quads:
Calves:

4. Fitness Goals

Check all that apply:
Gain Muscle Compete In Bodybuilding
Lose Fat Compete In Other Sport (describe below)
Gain Strength Improve Appearance
Improve Aerobic Capacity Improve Athletic Performance

Please describe in more detail what you wish to gain from an exercise and nutrition program. Specifically, which of the above options are most important to you and why? If you want to lose fat, where do you carry most of your unwanted fat?

5. Current State of Training

How many years have you been training?
How often do you lift weights? How long is a typical workout?

How often do you do aerobics? How long is your typical aerobic workout?

Describe in detail the nature of your weight and aerobic workouts.

6. Current State of Diet

How many times do you eat a day?
How many cups of water do you drink a day?

Describe the nature of your meals -- a typical day. Do you cook for yourself?
Can you cook? Do you eat out often?

What are some of your favorite foods? Include protein and carbohydrate sources.

Do you take supplements? Are there ones you would like to integrate in your diet?
How much money are you able to spend monthly on supplements?

Do you drink alcohol? When and how much?
Do you drink coffee or caffeinated products? How often or cups/day?

7. Lifestyle

What is your job?:
What type of physical work, if any, does your job require?

What are your regular hours?

What time of the day can you work out? When do you prefer? Weekends? Weekdays?

8. Overall Health

Do you have any health concerns? Chronic injuries? Any concerns or limitations in general?

9. Billing Information
(If you wish you mail a check, leave this blank. Please note that submitting a credit card will greatly speed the creation of your custom workout/diet plan).

Card Type:
Card Number:
Expiration Date:
Comments:
DISCLAIMER
As with any exercise program, always consult with your physician before starting. If at any point while following ant customized diet or workout program, you feel sick, dizzy, nauseous, faint, chest discomfort, shortness of breath, pain or and other type of discomfort, stop immediately and consult your physician. Please read all the instructions, cautions, and/or warnings before taking any supplements that are recommended to you. If a problem arises during usage, stop immediately and consult your physician.

Check here to verify that you have read and understand the above warnings.

Please check to make sure you filled out every form correctly.
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Thank you for your order.


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