Are you ready to take the next step, or simply have some more specific questions
that you would like answered? To easy, all you need to do is complete the form
below and I will personally be in contact with you within 24 hours.
Additionally, if you are a Albury/Wodonga resident, fastest response is via
phone so feel free to give me a call - 0439 884 148
Name
Email
Address
Home/Mobile Phone
Work Phone
What time is best to call
you? (very important)
Age
Spouse's Name
Your Occupation
Past and Present Medical History
Blood Pressure
Heart Problems
Diabetes
Fatigue
Anxiety
Arthritis
Bursitis
Muscle Tension
Knee Problems
Shoulder Problems
Tendon/Joint Problems (if yes please explain)
Back
Problems (if yes please explain)
Past and Present Exercise
History
Currently Exercising (if yes please explain)
Interests and Goals
Lose Body
Fat
Build
Muscle
Healthy
Living
Reduce
Inches
Less Stress
Tone/Firm
Up
Gain Weight
Cardio
Strength
Escapism
Energy
Group
Classes
Stamina
Rehabilitation
One on one
Education
Advanced Bodybuilding/Competition
Other
Present Physical Condition
Rate your Physical
Condition
Your Height
Current Weight
Your weight 2
years ago
Employment
Outside Activities or
Recreation
Married
Children
Doctor's Name
Electronic Signature
Intent
Habit Tracker
Eat 3 Meals a Day
How Often:
Fast Food
Alcohol
Restaurant Food
Coffee
Smoke
Snacks
Soft Drink
Watch TV
Supplements
8 Hrs of Sleep Daily
Lets see how you eat - can
you list a typical day?
Breakfast
Morning Snack
Lunch
Afternoon Snack
Dinner
Deserts (if app.)
Anything else
Six Month Goals!
Arms
Legs
Waist
Chest
Heart Rate
Hips
Back
Program/Service that interests
you
Select from the
menu
Referral Name
(Has someone recommended us to you?)
Name
Email
Phone
Please contact me as soon as possible regarding this matter.
Thank you for your
submission.
I will personally respond to
your submission within 24 hours, and then we can book in your obligation
free consultation to see how we can help you reach all of your health and
fitness ambitions
