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6WK Fat Loss Enrolment
Before our first session please complete the following form for my records.
Name
*
Address
*
Email Address
*
Emergency Contact Details (Only Fill Out If Having PT Package)
Doctors Details (Only Fill Out If Having PT Package)
Have You Experienced Any Heart Problems
*
If 'Yes', Specify in what in 'other' box
Yes
No
Do You Have Diabetes?
*
If 'Yes', Specify in what in 'other' box
Yes
No
Have You Ever Had A History Of Cancer?
*
If 'Yes', Specify in what in 'other' box
Yes
No
Do You Suffer From Epilepsy?
*
Yes
No
Do You Ever Experience Pains In Your Chest or Heart During Physical Activity?
*
If 'Yes', Specify in what in 'other' box
Yes
No
Do You Ever Get Dizzy Spells?
*
If 'Yes', Specify in when in 'other' box
Yes
No
Do You Get Out Of Breathe Easily?
*
If 'Yes', Specify in when in 'other' box
Yes
No
Do You Have Joint or Bone Problems That Could Be Aggravated By Exercise?
*
If 'Yes', Specify in what in 'other' box
Yes
No
Has Your Doctor Ever prescribed Medication For Blood Pressure Or Heart Conditions?
*
If 'Yes', Specify in what in 'other' box
Yes
No
Are You Currently Pregnant?
*
Yes
No
Have You Given Birth Within The Last 2 Years?
*
If 'Yes', Specify in when in 'other' box
Yes
No
Have You Been Advised Against Physical Activity By Your Doctor?
*
If 'Yes', Specify why in 'other' box
Yes
No
Have You Had Any Surgery In The Last 10 Years?
*
If 'Yes', Specify what in 'other' box
Yes
No
Do You Have High Blood Pressure
*
If 'Yes', Specify when last tested in 'other' box
Yes
No
Not Sure
Do You Have High Cholesterol?
*
If 'Yes', Specify what and when last tested in 'other' box
Yes
No
Not Sure
Do You Have A History Of Heart Disease In Your Family?
*
Yes
No
Not Sure
Do You Smoke?
*
If Used To, Specify When You Quit In The 'Other' Box
Yes
No
Please Specify In The Box Anything Else Not Covered Above You Think I Should Know In Relation To Your Health & Medical History?
On A Scale 1-10 (1 Mega Stressed - 10 Mega chilled) How would rate your levels of stress?
*
What Factors Would You Say Stress You Out The Most On A Regular Basis?
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On Average How Many Hours Sleep Do You Get A Night?
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How Would You Rate The Quality Of Your Sleep? (1 - Have trouble getting to sleep & regularly wake up - 5 I'd sleep through a hurricane)
How Would You describe Your Energy Levels Over The Day?
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What Is Your Goal Coming Into This Programme?
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What Would You Notice Is Different At The End Of This Programme That You Would Consider It A Success?
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What Challenges Do You Feel You Face That Could Prevent You From Losing Weight?
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Describe Your Current Situation?
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What Have You Tried Previously In Order to Lose weight? Write it as a list and indicate the level of success next to it.
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What will you be doing differently once you have achieved the level of weight loss you want?
*
Please indicate which facility is more convenient for you to attend?
*
Canton
Whitchurch
Cathays
Please select what times you are more likely to regularly be able to attend over the 6 week period?
*
7am-9am
10am-3pm
6pm-8pm
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What is your Everyday Health Score?
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