New Client Information

Please complete the following as honestly as possible so I can build your bespoke Health plan. All information provided is treated with strict confidentiality.

Your name *
Your age *
Your height *
Your weight *
Your contact details *
How would you prefer to be contacted?

How would you prefer to be contacted? Phone Email Zoom
Your lifestyle (job, hobbies, active, sedentary) *
Do you currently exercise - please give details: *
Your diet history - please give details: *
Daily water intake (in litres) *
Do you smoke?

Do you smoke? Yes No
Please state weekly alcohol consumption and amounts. *
Average hours sleep nightly:

Average hours sleep nightly: 3-5 hours 5-7 hours 7 + hours
Do you have any outlying conditions such as chrons, diabetes etc? *
Do yo have any current symptoms - fatigue, bloating etc. *
Your general mood and feelings right now & recently: *
Are you taking any medication and/or supplements? *
Are you suffering form any type of injury? *
Do you have any dietary restrictions? *
Your goals: Important! Tell me what your goal is and what you wish to achieve from my coaching, tell me any deadlines / timeframes. *
Please tell me your current food & drink diary that covers a few days so that I can assess where you’re at right now, and get to know you & your lifestyle better. *
I agree to the disclaimer here and confirm the answers given to the above questions are true. *

I agree to the disclaimer here and confirm the answers given to the above questions are true. I agree