First Name
Surname
Email
Phone Number
Age
Age
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
Height
Your height in feet or cm
4'0"/121 cm
4'1"/124 cm
4'2"/127 cm
4'3"/129 cm
4'4"/130 cm
4'5"/134 cm
4'6"/137 cm
4'7"/139 cm
4'8"/142 cm
4'9"/144 cm
4'10"/147 cm
4'11"/149 cm
5'0"/152 cm
5'1"/154 cm
5'2"/157 cm
5'3"/160 cm
5'4"/162 cm
5'5"/165 cm
5'6"/167 cm
5'7"/170 cm
5'8"/172 cm
5'9"/175 cm
5'10"/177 cm
5'11"/180 cm
6'0"/182 cm
6'1"/185 cm
6'2"/187 cm
6'3"/190 cm
6'4"/193 cm
6'5"/195 cm
6'6"/198 cm
6'7"/200 cm
6'8"/203 cm
6'9"/205 cm
6'10"/208 cm
6'11"/210 cm
Other
Current Weight (First thing in the morning)
Current Weight in Kilograms
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
Natural or Enhanced
Body Fat Percentage
How long have you been training?
How many times a week do you train?
How long is each session?
What cardio do you do? How long and how much?
What is your Occupation?
What are your goals and what are you wanting to achieve through training?
Do you have any Food allergies? Please List:
List 3 FAVOURITE FOODS you CAN’T live without (can be anything)
How many calories do you consume a day? (Roughly – estimate)
How long have you been eating this many calories and what is your progress?
Do you currently follow specific macros? If so what are they? (Include Fibre)
Do you previously or currently have any health conditions/issues?
Have you ever had any injuries or currently have any that may need to be addressed? FOR GENRALISED PROGRAMS WRITE HERE WHICH ONE YOU WOULD LIKE!
Acknowledgement of Questionnaire, Waiver and Evaluation form
By adhering to this diet plan, you understand with full knowledge the requirements, ramifications and consequences of the participation in nutrition activities and do so at your own risk. You MUST strictly inform me of any allergies, in-capacities, restrictions or injuries you have had, may have or do have. You will accept full responsibility for any injury, loss, damage or the like to yourself that may arise directly or indirectly from your participation in this diet or training program. You understand that macro-nutrient plans are NOT diet plans and any nutritional information should simply be taken as guidance. You acknowledge that exercise training programs including online training and/or plans are NOT refundable. This form MUST be signed and emailed/sent back before the commencement of your diet or exercise training program.
- You are not allowed to copy, distribute, share and/or transfer the product/s and/or associated information provided as a result of or in connection with this diet or exercise training program to any third party or person without express written authority
- It is your responsibility to provide me with accurate information. Your failure to provide up to date accurate information may obstruct and hinder the results of your participation in this exercise or diet training program, for which you accept full liability
- The nutritional guidelines provided to you are not formulated to suit any nutrient deficiencies, allergies or any other food related health problems. It is to be used as a GUIDE for your consideration and in conjunction with the other aspects of this diet or exercise training program. If you have any concerns or are unsure about anything pertaining to the nutritional guidelines provided to you, it is your responsibility to seek your own independent information as to whether they are suitable for your dietary needs and circumstances.
- It is your responsibility to honestly track your weigh ins and macros
- It is your responsibility to implement and manage the macro/cardio targets given to you
- It is your responsibility to keep up with weight training adherence as expected
- You understand that I am a Personal Trainer, not a nutritionist, and all information specified is merely guidance and advice with relevant recommendations and suggestions specific to your goals
- If you don’t understand something or have any concerns about any activity involving the exercise training program, it is your responsibility to seek clarification and guidance
***You must adhere to the Terms & Conditions of Service agreement and Membership agreement***
SUBMIT INFORMATION