Enquiry Form

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

For a more extensive questionnaire (WORD format) - click here

 
 

CLIENT APPLICATION FORM

 

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 (if applicable)
Name
Email
Phone
 
Please contact me as soon as possible regarding this matter.

          

 
 

Thank you for your submission.

 

Waiver and Release of Liability (WORD format) - click here

Informed Consent (WORD format) - click here