First name*
Last name*
Phone number*
Email*
Address line 1
Address line 2
City / town
County / state / province
Post / Zip code
Country
Emergnecy contact person*
Date of birth* Day12345678910111213141516171819202122232425262728293031
MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Year1920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010
Height (cm)
Weight (kg)
Sex MaleFemale
Are you active on a daily basis?* YesNo
Are you pregnant?* Not applicableYesNo
What do you do for a living?
Were you referred to us by one of our clients?* YesNo
If YES, please help us to reward them:
Referral first name
Referral last name
If NO, how did you hear about us? FriendYellow PagesAdvertisementVisited UsOther
Which of services interests you the most? 1on1 Personal TrainingGroup Session TrainingNutritional Coaching
Have you ever suffered from...? AsthmaHigh or Low Blood PressureEpilepsyDiabetesFrequent ColdsDizziness or FaintingHeart DiseaseShortness of breathHigh CholesterolHeadaches or MigrainesNONE
Have any of your first degree relatives experienced the following conditions? Heart AttackHigh CholesterolHigh Blood PressureCongenital Heart DiseaseDiabetesNONE
Have you had surgery in the last two years? YesNo
If YES, please provide details
Do you suffer from back pain? YesNo
Do you have any injuries? YesNo
Do you take any MEDICATIONS or Supplements? YesNo
When where you in the best shape of your life? Year1920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010
What where you doing? Whats different now?
How would you rate your current physical fitness? (1 = Poor, 10 = Athelete) 12345678910
How would you describe your nutritional habits? BadGoodOptimal
Have you ever suffered from any of the following? Digestive Problems (IBS, Bloating etc)AllergiesKidney ProblemsFood IntolerancesNONE
1.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT
All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I AGREE to the above terms and conditions
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