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Dr Fitness and Nutrition
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Name *
Email address *
What is your gender? *
Male
Female
Rather not Say
What is your Date of Birth? *
Please give your doctors Info i.e address, phone number and Doctors name *
Do you have any Medical conditions. *
How tall are you? (cm) *
What is your weight? (kg) *
Do you smoke? *
Yes
No
How Many units of alcohol do you drink a week? *
I don't drink
0-8
9-14
15-20
21-25
26+
What do you do for a living? *
How often do you eat/drink junk food, such as fizzy drink, takeaway, sweets, crisps etc? *
Never
Hardly ever
Often
Most of the time
How often do you prepare your own meals from scratch? *
Never
Hardly ever
Often
Most of the time
How many hours do you spend in front of a screen per day? i.e. TV, Computer, phone *
0-3 hours
4-6 hours
7-10 hours
11+ hours
Please tell me what your goals are. Break these into Short (Up to 3 months), medium (3-9 months) and long (9-12 months) term. *
How many hours a night do you sleep? *
Less than 3
3-5
5-7
8+
Do you have access to a gym? *
No, I have no equipment
No, I have basic equipment at home
Yes, Home gym with limited equipment
Yes, with lots of equipment
Are you currently exercising? *
No
Yes, do my own thing
Yes, following a plan
How many days a week do you plan on exercising? *
1
2-3
3-4
4-5
6-7
How many hours a day can you commit to training? *
Less than 1
1-2
2-3
What exercises do you like? If you dont know, please leave blank
What exercises do you not like? I can't promise you wont ever do these but I will try to keep them to a minimum
Are you willing to share before and after pictures? *
No
Yes, but I don't want them on social media
Yes, you can share on social media but cover my face
Yes, I'm happy for to be shared on Social media.
I understand there are always risks associated with any exercise programme. I acknowledge DR Fitness and Nutrition are not responsible for any injuries that may occur *
I have read the Terms and Conditions *
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