Name: / Email:
Address:
Mobile: / Height: / Age: / M/F:

Your Goals

What are 3 goals you want to achieve?
1.
2.
3.
What has made you decide to take action now to achieve these goals?
Do you need nutrition coaching or are keen for personal training?

Your Current Nutrition

What do you usually have for breakfast?
Do you skip breakfast?
What would you typically eat mid morning?
What do you usually have for lunches?
Do you make your lunch or buy it? Or a mixture of the two options?
What do you have mid afternoon to eat and or drink?
Do you snack after work? If yes, what do you have?
What do you typically have for dinners?
What snacks or treats do you like and when?
Are your weekend food choices much different to your weekday?
What common foods do you NOT eat?

Your Current Exercise

What is your typical weekly exercise routine?

State the time of the day you usually do each session.

Mon:
Tue:
Wed:
Thu:
Fri:
Sat:
Sun:
Do you like to exercise, or is it more because you feel you have to?

Your Lifestyle

What time do younormally wake?
Do you wake refreshed or tired?
What time do you usually turn your lights/devices off to sleep?
How well do you sleep?
Are you stressed at present or recently?
How many times would you get sick in a year?
How many coffees and other caffeine drinks a day?
How manycafe style milky coffees a day?
How much water do you drink a day?
How many nights a week do you drink alcohol?
How many alcoholic drinks on a weeknight? And a weekend night?
How often do you go grocery/supermarket shopping?
What, if any, supplements do you take?
Can you cook?

Your Health

Do you have a history, or is there a family history of any of the following?
Please highlight the appropriate response
Diabetes / yesnounsure / Heart disease / yesnounsure

Eating disorder

/

yesnounsure

/ Thyroid / yesnounsure
Low levels of Iron / yesnounsure / High cholesterol / yesnounsure
High blood pressure / yesnounsure / Irritable bowel / yesnounsure
Do you have of the following health or lifestyle related conditions?
Arthritis / Anxiety / High stress / Poor sleep / Lack of sleep

PCOS

/

Excessive alcohol

/ Depression / Low energy levels / Mood swings
Chronic pain / Psoriasis or eczema / Pre menopause / Irregular period / Smoker
Any other comments?
Do you have, or have recently had any injuries that limit your exercise or activity?
What is the heaviest you have weighed and what year?
What is the lightest you have weighed and what year?
What were the reasons you weighed as heavy as you did and as light as you did?
Have you ever been on a diet before? If so please describe the type and results
Do you use a personal trainer? (please state their name and mobile)
Are you currently taking medication, or have you recently stopped taking medication? If yes, please state
Are you allergic to anything?
Any other comments that you may feel are relevant?
Late Cancellation Policy
Please give24 hour’s noticeby way of text or email if you are unable to make your appointment. Failure to give this notice period may result in you being charged the full session value. By making an appointment you are in agreement with these terms.

Thank you for taking the time to complete this form.

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