Application Form

CONGRATULATIONS on committing to the next stage in your growth, and a happier, healthier YOU!

Before we get started you need to fill in all the boxes below with as much information as you can.
This information is vital to make sure our experience of working together is GREAT!

Also, the information you are asked to provide below is 100% confidential.
It will take about 20 minutes to complete the form - please allow time to comfortably and peacefully fill this in.

* Indicates required field

Name *

First

Last

Email *

Home Phone/Mobile *

Best way to contact you and what time. *

How did you hear about me? *

Other - please specify *

Age *

Height *

Location *

Current Weight *

Time of birth *

Date of birth dd/mm/year *

Weight 6 months ago *

Desired Weight *

PERSONAL INFOMRATION

Marital Status *

Children *

Occupation *

Tell me a little bit about you: what your current passions are, what floats your boat, what drives you mad! *

YOUR HEALTH & YOU

Describe your current health. *

How do you generally feel within yourself? (mental, physical, emotional, spiritual, sleep, day to day) please be as honest as possible *

What parts of your health (physical and emotional) would you like to improve? *

Describe below if you have any allergies? including foods? *

What medication and supplements, if any, are you on or have been on recently? *

Describe your health in your childhood, teens and early life. Please give as much detail as possible. *

I recommend that you get (1) your doctors consent before you start this programme and (2) a full and up to date set of blood work so that we have the most up to date information possible.

Please describe any family medical history which could be important to mention e.g.: type 2 diabetes; high blood pressure etc *

Please describe what diets and health protocols you have tried up until today and what your experience of those were. *

Describe what your approach to food and eating is. Do you emotionally eat? Do you eat until you've eaten too much? Do you forget to eat? etc... *

Importantly, what is your goal? What is it you want to achieve? Weight loss? Be active? etc... Please be as specific as you can. *

Any other comments *

THANK YOU for filling in this form. I will be in touch shortly to arrange our initial consultation. In the meantime if you have any questions please contact me here.

Please describe an average day of food. What do you eat for breakfast, lunch and dinner. There is no judgement so be as honest as possible. *

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