Simply-6 pre-course registration form

Simply-6 pre-course registration form

the first step in customising your experience is learning a little about you...
Your Details:
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
Mobile Number*
E-mail*
What would you like to achieve with Simply-6?
What does a successful outcome look like when you picture completing the six-weeks of this course?
Age*
used for caloric requirement calculations
Height*
used for caloric requirement calculations
Weight*
used for caloric requirement calculations
Do you have any dietary preferences:
Please mention any allergies, intolenaces, or dislikes to help tailor your meal plan examples.
Tell me a little about any previous experiences with diet or nutrition.
Have you tried anything in the past that worked well, or didn't work for you?
Do you have any injuries or limitations on movement and exercise?
We will discuss in more detail during your initial video consultation, but please mention anything relevent.
Do you have use of any of the following?

Fitbit or other smart watchBathroom scalesWhatsapp messengerActivity (step) tracking app' on phone
Do you have any home workout equipment you would like to utilise?
Please include overview of any home workout equipment that you would like to feature in your plans.
Are you currently taking any prescription medicines?*

YesNo
If yes, please list them below
certain medicines may influence the choices we make for exercise or dietary plans.
What would you like me to know about you that isn't covered elsewhere?
Tell me about you. What makes you tick
Should be Empty: