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Medical LAH

Personal Information

First name

Last name

Preferred name

ID number/passport

Age

Date of birth

Cellphone number

E-mail

Address

Town/city

Postal code

Metrics

Weight (kg)

Height (cm)

Goal weight (kg)

BMI

Calculate BMI = Weight (kg) ÷ [Height (m)]² Underweight: Below 18.5

Normal: 18.5 – 24.9

Overweight: 25 – 29.9

Obese: 30 or above

Suggested healthy weight (kg)

For Men: Ideal Weight = 50 kg + 2.3 kg × (height in inches − 60) For Women: Ideal Weight = 45.5 kg + 2.3 kg × (height in inches − 60)

How did you hear about us?

Marketer

Online

Social Media

Friend

Other

Agent

Please be sure to credit the referring agent, who has dedicated their time and effort and earns their income through your referrals.

Have you been in contact with an agent?

Yes