The information in this form is required to know a little more about you. To know what your goals are, know what you nutrition is currently like, know what your lifestyle is like. From this we will be able to work on the plan to reach your goals. Please be as honest as you can.

Name*

First Name Last Name

Email*

example@example.com

Phone Number

Area Code Phone Number

Date of Birth*

What are your goals you would like Rebel Gym to help you with?

If other please explain below what help you are looking for from Rebel Gym.

Current weight

85kg

Target Weight

80kg

Any Events coming up?

Holiday, Wedding, 5k

When is it?

6 months / August 2021

Your goals!

Drop dress size, sub 30min 5k

Any Events coming up?

Holiday, Wedding, 5k

When is it?

6 months / August 2021

Your goals!

Drop dress size, sub 30min 5k

What would you like to achieve in 3 Months?

Lose a stone, Learn how to exercise with good form.

In 6 months?

Run a half marathon, be confident going on holiday.

In a year?

Run a marathon, compete in a powerlifting comp

What would prevent you from achieving your goals?

If other please explain below.

Any minor injuries / tightness in muscles?

Tight quads, Tight Shoulders etc

If so how long has this been going on?

Days/ Weeks/ Months

Do you smoke?

Yes / No

If so how many a day?

10 / 20...

Do you drink alcohol?

Yes / No

If so how often?

daily/ weekly/ weekends

What type of work do you do?

Sit at a desk, physical - labouring.

Full Time / Part Time?

8 hour day / 12 hour day

How much sleep do you get?

3 hours, 5 hours, 7 hours etc..

Breakfast