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City / town
County / state / province
Post / Zip code
Emergnecy contact person*
Date of birth*
Are you active on a daily basis?*
Are you pregnant?*
What do you do for a living?
Were you referred to us by one of our clients?*
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?
If YES, please provide details
Do you suffer from back pain?
Do you have any injuries?
Do you take any MEDICATIONS or Supplements?
When where you in the best shape of your life?
What where you doing? Whats different now?
How would you rate your current physical fitness? (1 = Poor, 10 = Athelete)
How would you describe your nutritional habits?
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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