Consultation

1

Full Name* This field is required.

First Name

Last Name

2

Contact Number* This field is required.

3

Contact Email Address* This field is required.

4

Email* This field is required.

5

Gender* This field is required.

Male

Female

Other

6

Date of Birth* This field is required.

7

Age (years)* This field is required.

8

Height (cms)* This field is required.

9

Weight (Kg)* This field is required.

10

What is your occupation?

11

What is the activity level at your job?* This field is required.

none(seated only)

Moderate (light activity such as walking)

High (heavy labor, very active)

12

Do you follow a regular working schedule, do you work days, afternoon or nights?* This field is required.

13

Please list any physical activities that you participate in outside of the gym/work setting:

If none then this can be skipped

14

Are you on any medication(s)?* This field is required.

Yes

No

15

If yes, please list them.

16

What additional therapies are being undertaken for the given health problem(s)?

17

Do you suffer from any injuries?* This field is required.

Yes

No

18

If yes, please list them.

19

What additional therapies are being undertaken for the given injury?

20

Are you experiencing any stresses or motivational problems?* This field is required.

Yes

No

21

If yes, how do you currently manage any stresses in you day to day life?

22

Do any diseases run in your family?* This field is required.

Yes

No

23

If yes, please list what disease(s) run in your family:

24

Do you suffer from diabetes, asthma, high or low blood pressure?* This field is required.

Diabetes

Asthma

High Blood Pressure

Low Blood Pressure

None of the above

25

Are you a smoker?* This field is required.

Yes

No

26

Do you regularly consume alcohol?* This field is required.

Yes

No

27

If yes, how many units do you consume?

28

Your current diet could be best characterized as:* This field is required.

low-fat

low-carb

high-protein

Vegetarian/Vegan

No special diet

29

Do you have any food allergies/intolerances?* This field is required.

Yes

No

30

If yes, what are they?

31

What are your most liked foods (Proteins & Carbs)* This field is required.

32

What are your most disliked food? (Protein & Carb)* This field is required.

34

On average how much sleep do you get a night? (round to nearest hour)* This field is required.

35

Do you have any difficulties falling asleep?* This field is required.

Yes

No

37

What following best fit in with your desired goal? Please select all that apply.* This field is required.

Improved endurance

Increased strength

Increased muscle mass

Fat loss

General Wellbeing

38

Why are your goal(s) important to you?* This field is required.

39

How often are you willing to train a week to reach your goal?* This field is required.

Days a week

40

Have you trained with a personal trainer before?* This field is required.

Yes

No

41

If yes, what kind of training did you do:

42

What are your favourite exercises?* This field is required.

43

What are your least favourite exercises?* This field is required.