12 Week Body Transformation Challenge Application Form

Click to edit*

MonthDayYear

Full Name*

PrefixFirst NameLast Name

Birth Date*

MonthDayYear

Age*

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

How did you hear about us?*

Current weight*

Current height*

Build*

I would like to loose? Please note this is your LONG TERM goal not what you want to lose in the next 12 weeks*

Do you currently exercise?*

YesNo

If yes please list what activities you currently do and how often

Do you drink alcohol?*

If so, how many glasses per week?

My bodies worst problem areas are?

Have any members of your immediate family also experienced weight gain?*

Are you a shift worker?*

Do you wish to become pregnant in the next 12 months?*

Are you menopausal?*

Have you had

Do you experience

Chest discomfort with exertionUnreasonable breathlessnessDizziness, fainting or blackouts

Cardiovascular Factors

You are a woman older than 55You have had a hysterectomy or are post menopausalYou smoke, or quit smoking in the last 6 monthsYour blood pressure is below 140/90 mm hgYou take blood pressure medicationYour blood cholesterol level is below 200 mg/dlYou are more than 45 kilos overweight

Other Health Issues

You have asthma or lung diseaseYou have burning or cramping sensations in your lower legs when walkingYou have musculoskeletal problems that limit you from exercising

If yes to musculoskeletal problems please list them here

You have concerns about the safety of exercise? Please write here

You take prescription medication? Please list them here

Other illnesses/conditions you think we should know about? Please list them here

List all vitamins, natural remedies and supplements you are currently taking

Your regular doctors name*

First NameLast Name

Doctors Phone Number*

Area CodePhone Number

Declaration

The health and medical information provided is true and accurate and to the best of my knowledge. Whilst I realise that I will be provided with an exercise and weight loss program that is safe and effective, I am choosing to participate at my own risk.

I declare that I am not pregnant and do not plan on becoming pregnant during the course of the challenge. If my health, or any other condition changes that would impact any of the above questions, I will advise my trainer and have this updated immediately.

Disclaimer

The information provided to me during the 12 week challenge will be useful information on weight loss, healthy eating and exercise and is not intended as a substitute for advice from a medical practitioner or health care provider. Before starting any weight loss program or exercise you should gain advice or guidance on any health conditions/illnesses.

Other Terms

I understand that all information provided to me will be kept confidential and not shared with others.

I understand that everyone will lose weight at different rates and so I may lose weight slower or faster than others I have seen.

Upon signing this application I understand that I am liable for all the costs associated with this challenge, and that no refunds will be available. The only would be, if a Doctors letter was received advising that you were unable to continue due to a medical condition, at which point ou would be entitled to a pro-rated refund of your remaining program.

I have read the above statements and agree to follow the program exactly as outlined by my weight loss consultant. I have read this application form in its entirity including the declaration, disclaimer and other terms sections and understand the information that has been provided to me....

Full Name

First NameLast Name

Click to edit

MonthDayYearHourMinutesAM/PM Option

Signature