Personal fitness training / wellbeing development / nutrition and weight management mentoring
Please be detailed with your responses.
Name
*
First Name
Last Name
Date of Birth
*
If under 16 parental consent is required.
Address
*
Address 1
Address 2
Town
County
Post Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
Emergency Contact Number
*
Do you have any of the following?
*
Heart disease or Heart conditions - or any family releated Heart problems
Raised BP
Cholesterol problems
Diabetes - Type I or Type II
Gastrointestinal problems
Food allergies or intolerances
Joint problems
Chest pain or dizziness when exercising
Are you pregnant or Breastfeeding (if yes, add note below)
Are you taking medications
Do you smoke or drink excessively (if yes to either, add note below)
Anything else you would like to let Emma Jane Taylor know about, regarding your health?
Nothing more to add
Other
Use this to add detail to your answers above or add N/A
*
If you could change one thing about yourself right now, what would it be?
*
What is your biggest fear in life? And why?
*
What are your strengths and weaknesses?
*
How would YOU describe yourself?
*
How would OTHERS describe you?
*
What holds you back in life?
*
Do you have regrets about anything in your life to date?
*
What would you like to achieve by doing these sessions with Emma Jane?
*
Is there anything you would like to know about Emma Jane and the programme you are undertaking with her
*
Is there anything else you feel would add value to the work you will be doing with Emma Jane to enhance your journey today and in the future
*
SIGNED
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Save
SUBMIT HERE. Emma Jane Taylor will be in touch to discuss as needed
SUBMIT HERE. Emma Jane Taylor will be in touch to discuss as needed
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