CONSULTATION FORM

Please complete the following form in as much detail as possible

Consultation Form

Name

Address

Email

Phone Number

Date of Birth

Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse with exercise?:

YES

NO

Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse with exercise?:

YES

NO

Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse with exercise?:

YES

NO

Do you have Diabetes Mellitus or any other metabolic disease?:

YES

NO

Has your doctor ever said that you have raised cholesterol (serum level above 6.2mmol/L)?:

YES

NO

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by your doctor?:

YES

NO

Have you ever felt pain in your chest when you do physical exercise?:

YES

NO

Is your doctor currently prescribing you drugs or medication?:

YES

NO

Do you often feel faint, have spells of severe dizziness or have lost consciousness?:

YES

NO

Do you currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women)?:

YES

NO

Do you currently smoke?:

YES

NO

Do you currently exercise on a regular basis (atleast3times a week) and work in a job that is physically demanding?:

YES

NO

Are you, or is there any possibility that you might be pregnant?:

YES

NO

Do you know of any other reason why you should not participate in a program of physical activity?:

YES

NO

If you are currently training, in as much detail as possible please describe your current training plan::

How many times a week are you able to commit training, and for how long per session?:

What equipment do you have access to?:

What are your exercise likes and dislikes?:

Injury history overview:

In as much detail as possible please describe your current daily diet:

What do you believe to be your biggest barrier in relation to training & nutrition? Do you have any weaknesses in your current diet?:

Please list your food likes & dislikes

Do you have any food allergies and/or known intolerances?:

Current total bodyweight in KG/height in M/age:

Program goal: What would you like to achieve?:

Submit