Please recognise that it is your responsibility to work directly with your doctor before, during and after seeking a fitness or nutrition consultation. As such, any information provided is not to be followed without the prior approval of your doctor. If you choose to use this information without the prior consent of your doctor, you are agreeing to accept full responsibility for your decision. 

Name: *

First

Last

Gender: *

D.O.B *

Email Address: *

Tel No: *

GOALS *

Please state the 3 most important benefits that you would like to achieve?Please outline your ultimate goal. What are you looking to achieve?Be as specific as possible.

Are you training for a specific sport or event?  *

• Yes
• No

If so, what is the timeframe for your goal?

What type of results are most important to you? Please select based on the statements below. *

• Immediate results that require strict adherence and may be harder to maintain long term
• Maintainable progress that may not be as rapid

On a scale of 1-10 (one being farthest away) where are you now in relation to your goal? *

How do you currently feel about the situation? *

To what extent are you prepared to change your lifestyle (based on recommendations) in order to improve your health and fitness? *

What (if anything) could knock you off track? *

What are your weak points/bad habits? *

Please specify how many hours per week you intend to exercise? *

Submit

The following questions help me to understand how best to design your plan. Please answer as honestly as possible.

If you answered YES to all of the below then you are ready to go.

Have you set a clear goal about what you want to achieve? *

• Yes
• No

Have you accepted that you need to make permanent (not temporary) changes to your lifestyle and eating to be successful? *

• Yes
• No

Have you thought about your current eating habits and understood that some things need to change? *

• Yes
• No

Are you undertaking this programme for YOU (and not because someone said you should)? *

• Yes
• No

Name *

First

Last

DATE *

Submit