Name
Address
Phone (H)
Phone (W)
Phone (M)
Email
WEIGHTLOSS (Tick one or more of the boxes) Reduce body fat Firm and tone up Improve self image Look and feel good
WELLBEING Improve fitness Reduce blood pressure Increase energy Increase stamina
SPORTS SPECIFIC Increase power Increase flexibility Increase agility Sports conditioning
REHABILITATION Injury recovery Accident compensation Mobility Pain reduction
Are you currently on any medication? If yes, please give details.
Do you have high blood pressure? Yes No
Do you have any of the following injuries or conditions? Osteoarthritis/Osteoporosis Joint pain Neck or back pain Diabetes Cardiovascular disease or hypertension Respiratory disorders
How would you describe your current condition?
Why are you in this condition?
When would you like to achieve your results by? (month)
How important is it for you to achieve those results?
How many times per week can you come into the club?
Do you prefer to exercise Alone With a friend With a coach
What time of day would you prefer to come to the club?
How long have you been thinking about doing something to achieve your desired results?
On a scale of 1-10, how serious are you about getting started at this time?
What has kept you from starting sooner?
Is that still a problem?
Do your family and friends support you in starting a program?
Please note that your contact details will only be used to contact you as you request, and will not be passed onto any other parties.
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