Hybrid Health Consultation Form

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Full Name
First Name
Last Name
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Best Contact Number * This field is required.
Please enter a valid phone number.
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Email* This field is required.
example@example.com
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Gender
Male
Female
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Date of Birth
Day
Month
Year
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Height
cm
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Weight
Weight
Goal Weight
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OccupationThis tells me how active you are during the day
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General Health - Please explain any health concerns you or your health professional may have in regards to your training (if you have ticked any of the above medical & health issues, please include a detailed explanation)
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Please select all the apply?
Asthma
Family History of Heart Disease (please specify below)
Diabetes
Joint implants or other implants (please specify below)
Substance use or dependancy
Smoker
Pregnant or possibly pregnant
Muscular related issues
Medication (please specify below)
Any Previous injuries
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Please state all (if any) medications or supplements you are currently taking including frequency and dosage.
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If you have any injuries, please list them.
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Please list:
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Training - What training facility do you have access to?* This field is required.We can work with anything!!!
Commercial Gym
Home Gym (DBs Only)
Home Gym (Fully equiped)
Other
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What is your Main Goal?* This field is required.Just one goal that is the most important to you
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Why?
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How often can you train each week to reach your goal?The minimum amount of days your can commit to training.
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Are you currently excersising regulary (at least 3x per week)?
Yes
No
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Have you had a Coach before?
Yes
No
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How was your experience?
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At what times during the day would you prefer to train?
Morning
Mid-Day
Afternoon
Evening
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Nutrition - What is your preferred way Nutrition Guidance?* This field is required.
Meal Plans + Calories Counting (Premium)
Calorie Counting (Foundation)
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Nutrition - Please select what Protein Sources you prefer?
Chicken
Fish (white fish, tuna etc)
Salmon
Beef
Liver
Eggs
Yoghurt
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Please list any extra details that you prefer? (ie chicken thigh or Breast, steak or mince or fish?
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Nutrition - Please select what fat sources you prefer.
Avocado
Nuts (almonds, walnuts, pecans, etc.)
Seeds (chia seeds, Flax seeds, etc)
Olive Oil
Coconut Oil
Butter
Cheese
Fatty Fish (salmon, sardines)
Dark Chocolate
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Please list any details about the types of fats you prefer (ie what nuts, type of fatty fish)
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Nutrition - Please select what carbohydrates you prefer.
Rice (white or Brown)
Bread (whole grain, white, etc.)
Pasta (whole death, white, etc.)
Potatoes (sweet potatoes, regular potatoes etc)
Fruit (apples, bananas, oranges, etc.)
Vegetables (Broccoli, carrots, Spinach, etc.)
Oats
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Please List any details on carbohydrates that you prefer? (ie - Types of potatoes, fruits, Rice etc )
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Are there any foods you will not eat and do not want to be included in your meal plan? Be fussy! It's your life :)
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FOUNDATION COACHING

TRAINING ONLY (access to all training programs)

Included
- Fortnightly Check ins
- Customised Training Programs
- Macro and Calories Targets

- Access to a mobile app
- Daily tasks and calendar
- Free meal plan template
- Video demonstrations of exercises, workout schedule, and the option to track weights

(8 week minimum commitment)
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PREMIUM COACHING

TRAINING & NUTRITION

Included
- Weekly Check ins
- Nutrition Plans (Updated Nutrition Weekly)
- Training Programs (Program adjustments Weekly)
- Access to a mobile app
- Daily tasks and calendar
- Habit Tracker
- Step and cardio guidelines
- Video demonstrations of exercises, workout schedule, and the option to track weights

(8 Week minimum commitment)
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What service(s) are you interested in?
Foundation (Training Only) - $60 p/w
Premium (Training & Nutrition) - $80 p/w
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When is a good time for me to call? Just leave blank if you don't want a phone call This is where we will go over your consult and create a game plan to help you the best I can.
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By ticking the box below you agree that to the best of your knowledge the information you have supplied to Hybrid Health is correct. Nothing on this site is intended to establish a physician-patient relationship, to replace the services of a trained physician or health care professional, or otherwise to be a substitute for professional medical advice, diagnosis, or treatment.

I am aware of the risks in observing or participating in the activities offered and sponsored by Hybrid Health and I understand that all physical activity that I will execute and participate in are entirely at my own risk. I realize that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death. It is understood that Hybrid Health is responsible for any damage that would be resulting from a fault of Hybrid Health and its representatives.

I understand that when signing on as a client of Hybrid Health I will be engaging in a program that has a minimum time frame of 8 weeks to receive my results. If I do not see changes within the first 30 days after following the plan consistently, I understand I will receive my money back.
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I AGREE TO THE ABOVE TERMS & CONDITIONSSign Here
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