Experienced User Form
Please complete all sections and sign at the end.
Name
*
First Name
Last Name
Date
*
-
Day
-
Month
Year
Date
Contact Details (Phone Number)
*
Email
*
example@example.com
Date of Birth
*
-
Day
-
Month
Year
Date
Emergency Contact Name
*
Emergency Contact Number
*
Site
*
Please Select
Bucklers Mead Leisure Centre
Exmouth Leisure Centre
Exmouth Tennis & Fitness Centre
Honiton Leisure Centre
Ottery St Mary Leisure Centre
Sidmouth Leisure Centre
The Engine
The Grove (Seaton)
The Hangar Health & Fitness Centre
The Space Health & Fitness
Would you like to be contacted by our Fitness and Wellbeing Coach?
Yes
No
Please complete the fields below
What is your biggest Lifestyle Concern
*
Please Select
Fitness
Nutrition
Sleep
Alcohol
Smoking
Stress
Anxiety
Illness
N/A
Other
Usual Gym Name
*
Date of Last Gym Session
*
What are you hoping to achieve by coming to the gym?
*
Please Select
Fitness
Strength
General Wellbeing
All of the above
What has made you feel you need to achieve this?
*
How do you want to feel in 6 months?
*
How do you feel about exercise?
*
How motivated are you to achieve your goals? 1 = low 10 = high
*
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
How is your diet? 1 = Poor 10 = Good
*
1
2
3
4
5
6
7
8
9
10
1 is , 10 is
Any Health Issues (Please list and inform a member of the staff)
*
What days / times are best for you to exercise?
*
Health Commitment Statement
I can confirm I am a experienced user, I have read the Health Commitment Statement.
*
I can confirm I am a experienced user, I have read the Health Commitment Statement.
*
Submit
Should be Empty: