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New Client Registration

Personal Information

Next of Kin

Training Information

Personal Training Group Training

Medical Information

High Blood Pressure
Low Blood Pressure
Arthritis
Constipation
Diabetes
Frequent Colds
Dizziness/Fainting
Shortness of Breath
High Cholesterol
Headaches
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Lifestyle Questionnarie

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Health Check Questionnaire

All details will be held private and confidential. The more information you provide, the better we can help you.
Do any of the following apply?

Currently following a medically prescribed diet

Currently undergoing medical treatment

Are you pregnant, or aiming to become pregnant

Do you have a medically identified food allergy or intolerance

Please list any supplements you are taking and dosage:

Family history of allergies

History of a severe allergic reaction/anaphylactic shock

Been tested for food intolerances

History of health problems or disease in your family?

Please list any foods and/or chemicals that you react to:

Please tick if you experience any of the following

Toxic Load Profile

Immunity Profile

Digestion/Elimination Profile

Sleep/Energy Profile

Mood Profile

Adrenal/Blood Glucose Profile

Stress Profile

Cardiovascular/Circulatory Profile

Female Hormonal Profile (women only)

Age at first period:

Age at final period:

Male Hormonal Profile (men only)

Dietary Analysis

Any foods that you crave

Any foods that you dislike

Favourite foods

Foods difficult to give up

Following a special diet, now or in the past?

Please tick if any of the following apply
  • Have experienced an eating disorder
  • Cater for a special diet in the family
  • Eat lots of wheat and dairy products
  • Eat out frequently
  • Have a repetitive diet
  • Cook for more than one
  • Enjoy eating and preparing food
  • Have a good appetite
  • Mainly purchase organic produce
  • Have you recently changed your diet
  • Find shopping easy
  • Add salt to cooking or food?
  • Add sugar to food or drink?
  • Drink decaffeinated tea or coffee?
  • Regularly eat fried food?
  • Regularly eat processed food?
  • Regularly eat ready prepared meals?
  • Regularly microwave food?
  • Avoid additives and preservatives?
  • Choose mainly low-fat food?
  • Eat take away more than once per week?
  • Eat mainly whole grain bread, rice, pasta & cereals?
How many of the following do you consume?
  • Biscuits in a week
  • Cakes/pastries in a week
  • Cups of coffee a day
  • Cups of tea a day
  • Cups of herbal tea a day
  • Pints of milk a week
  • Slices of bread in a day
  • Chocolate in a week
  • Glasses of water a day
  • Portions of oily fish per week
  • Cigarettes a week
  • Alcohol drinks per week