Name
*
First Name
Last Name
DOB
*
MM
DD
YYYY
Phone Number
*
Occupation
*
Level of activity at work
*
None
Minimal
Active
HIghly Active
Level of activity out of work
*
None
Minimal
Active
Highly Active
Details of daily activity
*
Do you get stressed?
*
Never
Occasionally
Often
Every Day
If yes, how does your stress effect you?
What is your current exercise level
*
What exercise do you do, how often, how long for and what's your effort level between 1-10 (10 been max effort)
Any exercise likes or dislikes
*
What would be a REALISTIC ideal exercise plan be like for you? Do you prefer to walk or jog, do HIITS, do more weights?
*
What would a REALISTIC ideal dietary plan for you? Calorie counting, Macro tracking, a set food plan or making small changes? What would work best for you and your lifestyle?
Please be honest, if you have other ideas please say.
How motivated do you feel?
*
Not
Slightly
Very
Extremely
How may days a week can you fit in exercise?
*
Please give details of times available.
Are you currently breastfeeding? If so, how often and how long does each feed last?
How old is your child / children?
Do you currently have regular periods? If so, how long is your menstrual cycle and what day are you on now?
*
If you are unsure on exact cycle details please just give a rough idea.
Do you have any special dietary requirements? Please explain.
*
How much water do you drink a day?
*
Do you have 3 meals a day plus snacks? Please give a brief daily diet.
*
How often do you eat out or order in and what do you eat?
*
On average how much sleep do you get a night?
*
Do you smoke or drink?
*
Give details of units of alcohol or number of cigarettes per day
What is your goal and when do you want to achieve this by?
*
What barriers could prevent you from achieving this goal?
*
To monitor your progress you need to provide photos. Please advise if you will be sending images over.
*
All images must be emailed to progress@phbp.co.uk within 24 hours of submitting this form.
Please title email with: Full Name - Progress Photos
Waist (cm)
Belly Button (cm)
*
Hips (cm)
*
Bum (Widest Part) (cm)
*
Upper Thigh, Left (cm
*
Upper Thigh, Right (cm)
*
Upper Arm, Left (cm)
*
Upper Arm, Right (cm)
*
Please confirm that you have read, understood and accurately completed this questionnaire. That you are voluntarily engaging in an acceptable level of exercise, and you understand that your participation involves risk of injury.
*
I CONFIRM AND AGREE
I DO NOT CONFIRM AND I DISAGREE