Welcome & Enrolement Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
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Other
Country
Phone Number
*
-
Area Code
Phone Number
Childrens Names & Ages
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Fitness Enrollment Information
Which Classes and events are you interested in?
*
4 WEEK CHALLENGE
CHILD FRIENDLY CLASSES
BOXING
DRUMFIT
ABS-BUTTS-THIGHS
BOOTCAMP
NUTRTION WORKSHOPS
How did you hear about us?
*
Flyer
Referred by a friend
Personal Invitation
FaceBook
Meet Up
Instagram
Glam Adelaide
Adelaidy
Email
Other
Invited by (name of Health & Fit Coach)
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Health & Lifestyle Questionaire
Do you feel you receive balanced nutrition from the foods that you eat?
*
No
Yes
How would you describe your energy levels?
*
Ok
Up & Down
Lethargic
Excellent
Would you like to improve your energy levels?
*
Yes
No
Would you like to: (choose whats applicable for you)
*
Lose Weight
Reduce Body Fat
Gain Muscle
Maintain weight
Improve general wellbeing
Lose Baby Weight
How much would you need to gain/lose to reach your ideal weight?
*
Do you exercise
*
Not at all
Occasionally
Regularly
If so, how do you like to move your body?
Walking
Running
Gym
Yoga
Pilates
Swim
Cycle
Dance
Team Sport
Barre
Golf
Other
Would you like to improve your sports performance/fitness/stamina?
*
Yes
No
On a scale of 1-10 (1=Not at all) + (10=I want it yesterday) how motivated or serious are you about reaching your goals as this time?
*
1
2
3
4
5
6
7
8
9
10
WORST
BEST
1 is WORST, 10 is BEST
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Medical Information
Do you suffer from any health complaints? Eg. asthma, allergies, diabetes,blood pressure, cholesterol, arthritis, skin disorders (acne, rashers, psoriasis, eczema) chronic fatigue, other?
Please provide and explain.
Please review the following check list
*
YES
NO
Do you smoke?
1
2
Drink Coffee or Coffee Drinks?
3
4
Drink energy drinks
5
6
Drink soft drinks
7
8
Do you eat breakfast?
9
10
Do you get at least 6-8hrs sleep
11
12
Do you drink at least 2L water
13
14
Do you eat take away food?
15
16
Do you eat fast food?
17
18
Crave sugar
19
20
Crave salt
21
22
Type a question
*
YES
NO
Back pain
23
24
Reflux
25
26
Depression
27
28
Anxiety
29
30
Bloating
31
32
Digestive Issues ie IBS
33
34
Indigestion
35
36
Water retention
37
38
PMS/Mood Swings
39
40
Pregnant
41
42
Breast Feeding
43
44
Menopause
45
46
Diabetes
47
48
Any other health conditions or past injuries?
Do you have any particular health goals in mind and any particular Special event/Wedding/Holiday?
*
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Disclaimer
FITNESS LIABILITY RELEASE WAIVER
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