Healthier Me 8 week Program | Your Fitness Goals

First Name

Email Address

Last Name

Cellphone Number

What fitness goals would you like to achieve in the next 8 weeks?

Name 3 things you could do in order to improve your health?

What are your main reasons for starting a fitness program?

General conditioning

Muscular strength

Weight /fat loss

Endurance

Appearance

Stress management

Flexibility

Improve self-esteem

How would you describe your general health and fitness?

Have you ever done any structured exercise? Yes / No If ‘Yes’ what did you do?

What type of exercise do you enjoy the most?

What type of exercise do you dislike the most?

What would you say are the main barriers preventing you from exercising?

Lack of facilities

No motivation

No time

Injury/illness

Unfit

Appearance

Lack of knowledge

Family

Work

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I declare that all Personal Information being supplied by me to Kirstin Sylvester Dietitians is accurate, up to date, not misleading, and that it is complete in all material respects.

I undertake to advise Kirstin Sylvester Dietitians immediately of any changes to my Personal Information, should any of the details change.

By providing Kirstin Sylvester Dietitians with my Personal Information, I consent and give the Company permission to process and further process the Personal Information, as and when required, that I supply to the business, understanding the purposes for which the Personal Information is required and for which it will be used.

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