I AM READY FOR A CHANGE! SIGN UP FOR YOUR MEMBERSHIP Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *SECTION 1: Physical Activity: 1A: In the last 12 months how often have you participated in some kind of exercise?3 to 4 times per week1 to 2 times per week1 to 2 times per month Not at all i.e. may have been due to pregnancy or ill health2B: What sport or activity has worked for you in the past?3C: What type of exercise do you enjoy and where do you go to take exercise?4D: What form of sport or exercise do you dislike and why? SECTION 2 Occupation / Leisure: 1A - What is your present occupation?2B: Does your occupation involve much physical exercise i.e. lifting, walking? 3C: What exercise or hobbies do you like to do in your spare time? SECTION 3 Stress: 1A: Rate yourself on a scale of 1 – 10. 1 being calmest 10 suffering badly1 2 3 4 5 6 7 8 9 10 What situations make you feel stressed? How do you relax? SECTION 3: Diet 1A: Do you think you eat a healthy diet?2B: Do you eat breakfast? 3C: Do you snack in between meals and if so what do you have ?4D: Do you think you eat more than you need?5E: How many calories do you think you consume in a day? 6F: How many liters of water do you drink in a day?SECTION 4: Weight 1A: Do you consider yourself overweight? 2B: . If yes, how much would you like to lose?3C: Is the rate at which you lose weight important to you? SECTION 5: FITNESS 1A: Rate yourself on a scale of 1 – 10 as to how fit you think you are:1 least fit 10 most fit enter the number that best applies. 1 2 3 4 5 6 7 8 9 102B: How good is your stamina? (1) No stamina (10) High staminaEnter a number 1 2 3 4 5 6 7 8 9 103C: How strong do you think you are?Enter a number 1 2 3 4 5 6 7 8 9 104D: How flexible do you think you are?Enter a number 1 2 3 4 5 6 7 8 9 105E: How coordinated do you think you are?Enter a number 1 2 3 4 5 6 7 8 9 106F: How much time will you have to do exercise?Please prove How many mins per day and How many days per week.SECTION 6: GOALS 1A: How much time would you like to to significant results?1 month 3 month 1 Year2B: Rate your goals in undertaking exerciseExtremely importantQuite importantNot very importantImprove overall health Selected Value: 0 Rate in your view, the following in importance 1 – 10.Improve your fitness Selected Value: 0 Rate in your view, the following in importance 1 – 10.Reshape or tone my body Selected Value: 0 Rate in your view, the following in importance 1 – 10.Improve my performance for a particular sport Selected Value: 0 Rate in your view, the following in importance 1 – 10.Improve moods and stress levels Selected Value: 0 Rate in your view, the following in importance 1 – 10.Improve flexibility Selected Value: 0 Rate in your view, the following in importance 1 – 10.Increase strength Selected Value: 0 Rate in your view, the following in importance 1 – 10.Increase energy levels Selected Value: 0 Rate in your view, the following in importance 1 – 10.Reduce medication intake Selected Value: 0 Rate in your view, the following in importance 1 – 10.Enjoyment Selected Value: 0 Rate in your view, the following in importance 1 – 10.Comment or Message *CommentSubmit
