Consultation

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Fill all form fields. Fields marked (*) are required. Please note that form categories are nested in sections. Be sure to tap on each section and fill appropriately.

Details About You
Your Name*
Title First Name Last Name
- Gender*
  - Male
  - Female
- Date of Birth*
  Date Format: MM slash DD slash YYYY
- Age*
- Phone Number*
- Your Email Address*
- Instagram Handle
- Preferred Mode of Communication*
  - Text Message
  - WhatsApp
  - Phone Call
  - Email
- Your Delivery Address*
- Occupation*
- No. of Children
- Marital Status*
  - Single
  - Married
  - Widowed
  - Separated
  - Divorced
- Height*
- BMI
- Current Weight*
- Target Weight*
- Bust*
- Waist*
- Hip*
- Dress Size*
- *
- Top Size*
- *
- Trouser Size*
- *
Emergency Contact
- Full Name*
  First Name Last Name
- Relationship*
- Email Address*
- Phone Number*
- Home Address*
Your Goals
- Proposed Start Date
  Date Format: MM slash DD slash YYYY
- Main Purpose for Wanting a Healthier Lifestyle:*
- Primary Area of Focus
- Preferred Coaching Period*
Have you had any previous experience in the following?
- Personal Training*
  - Yes
  - No
- Gym Membership*
  - Yes
  - No
- Dietician*
  - Yes
  - No
- Weight Loss Program*
  - Yes
  - No
- What was your last experience like?*
  - Poor
  - Fair
  - Good
  - Very Good
  - Excellent
- Complete this sentence*
  By the end of this experience, I will like to…
- Is there any aspect of this program that you will like to omit OR that may raise any concern(s)?*
  (If yes, please explain)
Your Current Lifestyle
- In your own words, describe yourself*
- In your own words, describe your diet*
- How would you describe your daily meal pattern?*
  - 1 meal a day
  - 2 meals a day
  - 3 meals a day
  - More than 3 meals
- How would you describe your daily snack pattern?*
  - I don’t snack
  - 1 snack a day
  - 2 snacks a day
  - More than 2 snacks a day
  - Other
- How many litres of waters do you drink daily?*
  - Less than 1 Litre a day
  - 1-2 Litres a day
  - More than 2 Litres
- How often do you drink alcoholic drinks?*
  - Never
  - Once a month
  - 2-4 times a month
  - 2-3 times a week
  - 4 or more times a week
- On average, how many hours of sleep do you get daily?*
  - Below 5 hours
  - Between 5-7 hours
  - Between 7 - 9 hours
  - Above 9 hours
- How would you describe your level of stress?*
  - Low
  - Medium
  - High
- How often do you smoke?*
  - Never
  - Occasionally
  - Regularly
  - Chain Smoker
- What is your Bowel movement like?*
  - Daily
  - Twice a week
  - 3-4 times a week
  - Irregular
- How often do you take nutritional supplements?*
  - Never
  - Daily
  - Weekly
  - Monthly
- How often do you exercise?*
  - Never
  - Daily
  - Weekly
  - Monthly
  - I don't remember
Your Medical History
- Doctor’s Name
- Phone Number
- Hospital Address:
- Have you ever had any of the following conditions?
  (Please tick all that apply)
  - Allergies
  - Anemia
  - Anemia
  - Asthma
  - Cancer
  - Concussions
  - Diabetes
  - Epilepsy
  - Gallstones
  - High Blood Pressure
  - Irritable Bowel Syndrome
  - Low Blood Pressure
  - Rashes
  - Stroke
  - Other
- Do you take any medication?*
  - Yes
  - No
- If you take medication, please describe what it is for.*
- Do you have any skin condition?*
  - Yes
  - No
- Are you currently Breastfeeding?*
  - Yes
  - No
- Do you have any allergies?*
  - Yes
  - No
- Have you had any surgical operation?*
  - Yes
  - No
General Food List
- List Your Food Likes
- List Your Food Dislikes
- What Snacks Do You Like
- What Snacks Do You Not Like
- *
  I consent to the use of this information
  We consider and treat the information you have provided as highly confidential, therefore these will not be shared to anyone but be used strictly for the purpose of which it was provided. For more information regarding the use of our website, please read our Privacy Policy and Terms.

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Consultation

Details About You

Emergency Contact

Your Goals

Your Current Lifestyle

Your Medical History

General Food List