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Consultation Form

Please fill out the following form.

First name

Last name

Email*

Age

Date of birth

Contact number

Emergency Contact

Family history or diagnosed heart disease?

No

Yes

Family history or diagnosed diabetes?

No

Yes

Have you had any recent injuries in the last 3 months?

No

Yes

If you answered yes to the question above, please supply additional information.

Do you have any other heredity conditions?

No

Yes

If you answered yes to the question above, please supply additional information.

On a 1-10 scale how do you rate your current health? (1 = poor 10 = excellent)

1

2

3

4

5

6

7

8

9

10

On average how many hours sleep do you get?

4-5

6-8

8+

What is the activity level of your occupation?

Sedentary

Lightly Active

Moderately Active

Very Active

Extra Active

Do you currently exercise?

Yes

No

If yes, describe the activity that you do for exercise:

How many hours over a week are spent in front of a TV, whether it be for watching or gaming?

0-2

2-4

4-6

6-8

8-10

10-12

12+

What days and times are you able to have your sessions?

In order of urgency what are the top three reasons for requiring coaching?

What are your top three physical goals?

Initials*

I declare that the info I’ve provided is accurate and complete.

CONTACT

Jenniecarwardine@gmail.com

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