Please be patient and fill in the required information carefully Elderly Step 1 of 7 14% (Required) First Name Last name Date of birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required) Level of education(Required)DiplomaBachelorMasterPHDField of Study(Required) Employment status(Required)employedretiredJob(Required) Phone Number(Required)Email (Result are sentvia email)(Required) Payment (50$ )Please email transfer to: Dr.Bahrami@gmail.com or Paypal to: Dr.Bahraminejad@yahoo.comThe name of the payer:(Required) Date of payment(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Payment receipt(Required)Max. file size: 2 MB. Height (cm)(Required)Current weight (measure your weight in the morning with underwear after toilet(Required)What is your normal weight? (kg)(Required)Waist circumference (Measure the smallest circumference with a tape(Required)Hip circumference (Measure the biggest circumference with a tape)(Required)3 points priorities of body fat distribution (Priority 1)(Required)Nonefront of abdomenthe sideshipthighchestthe armsPriority 2front of abdomenthe sideshipthighchestthe armsPriority 3front of abdomenthe sideshipthighchestthe armsFat percentage (with caliper or body composition analysis device)Send body composition fileMax. file size: 2 MB. Do you currently have a specific illness?NoYesPlease mention the type and duration of the disease(Required) Have you ever been hospitalized?NoYesPlease state the reason for hospitalization and its time in full(Required) Do you have a special injury or limited mobility?NoYesMention the type of injury or movement restriction(Required) At what times and with what factor does the pain intensify and subside?(Required) Have you ever experienced heart palpitations or shortness of breath?NoYesPlease describe the process of palpitations or shortness of breath(Required) Do you get dizzy and headache?NoYesExplain its type and amount(Required) Do you have digestive problems?NoYesExplain its type and amount(Required) If there is a particular disease in the first degree relatives, mention it(Required) Assess the stresses of your life and work environment(Required)lowmediumhigh Do you take any special medication?NoYesPlease specify the type and amount of medicine(Required) Do you take supplements or vitamins?NoYesPlease specify the type and amount of medicine(Required) Do you use cigarettes, alcohol or drugs?NoYesExplain its type and amount(Required) Are you allergic to a certain substance?NoYesExplain the type of sensitivity and its symptoms(Required) Can you raise both your hands above your head without pain?YesNoIn case of pain and disability, explain the conditions(Required) Can you easily rub the back of your shoulder from below with each hand?YesNoIf unable, explain(Required) Can you squat without knee and hip pain?YesNoIn case of pain and disability, explain the situation(Required) Can you touch your toes while sitting flat on the floor?YesNoIf unable, explain(Required) Can you run?YesNoIf unable, explain(Required) blood pressure (minimum)blood pressure (maximum)If possible, send a radiology picture of the kneeMax. file size: 2 MB.If possible, send a radiology picture of the lumbar vertebraeMax. file size: 2 MB. Purpose of training program(Required)Increase vitality and healthFitness without weight changeFitness with weight lossFitness with weight gainCure specific diseaseIf you need to change your weight, complete the food plan questionnaireFully explain your mobility limitation(Required) Do you have a special desire to shrink a part of your body?(Required)NoYesIf you need to change your weight, complete the food plan questionnairePlease name the desired parts(Required) Do you have a special desire to become muscular and bulky in a part of your body?(Required)NoYesPlease name the desired parts(Required) Do you have any special restrictions for going to sports places?NoYesMention the training location(Required) What training tools do you have?(Required) Do you have a desire to take supplements and vitamins?NoYesPlease send photos of your training equipmentMax. file size: 2 MB.Please specify only the days and times you want to do exercises (required).Morning Saturday morning Sunday morning Monday morning Tuesday morning Wednesday morning Thursday morning Friday morning Evening Saturday evening Sunday evening Monday evening Tuesday evening Wednesday evening Thursday evening Friday evening Which of the following methods do you prefer for endurance training? Free at the discretion of the coach Running in open space Running on a treadmill Outdoor cycling Stationary bike elliptical Swimming Mountain climbing Roping Which of the following methods do you prefer for strength training? Free at the discretion of the coach Strength machines free weights Body weight training rubber band Please provide a summary of your training record for the past 2 months(Required)Have you already received the training program from the site?NoYesIn what language would you like to receive your training plan?(Required)EnglishPersionPlease, in addition to criticisms and suggestions, if you think there is something special, write it in the form below.If you want, you can send a photo of your bodyMax. file size: 2 MB. While accepting the accuracy of the above information, I request the annual training program (required).
