BBM - From the Couch Kirikiriroa
Please register below if you're interested in taking part in our FREE 12 week Health & wellbeing program based in Hamilton You must commit to 3 x 1 hour sessions (Monday/Wednesday/Thursday) at 11am each week for the duration of the program. These sessions will include exercise, nutrition support and health checks.
CONTACT INFORMATION
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Format: (000) 000-0000.
NHI Number (if known)
Back
Next
Date of Birth
What is your age group
18-24
25-34
35-44
45-44
55+
What NHC clinic are you enrolled with?
Please Select
Rototuna Family Health Clinic
Avalon Medical Centre
Third Age Health Clinic
Rata Health
Hamilton Lake Clinic - grey street
If you are not enrolled with any of the above, please state your current clinic
Current weight (if known)
Are you able to commit to attending Monday, Wednesday and Thursdays at 11am for the 12 weeks? If not, please state your reason why?
Current Physical Activity - How many times per week do you exercise?
5-7 days a week
3-4 days a week
1-2 days a week
very rarely or not at all
Have you had or do you have any of the following conditions?
Respiratory (asthma)
High Blood Pressure
Stroke
Type 1 Diabetes
Type 2 Diabetes
Pre-diabetic
Gout
Blood disorder
Epilepsy
Heart attack
Arthritis
Other
Submit
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