Initial Client Form Date* MM slash DD slash YYYY Name* First Last DOB MM slash DD slash YYYY Address Street Address Address Line 2 Suburb State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email PhoneOccupation Have you ever experienced any of the following? Heart Trouble Pains In Chest Back Problems High Blood Pressure Epilepsy Dizzy Spells or Fainting Sports Injury Arthritis or Joint Pain Asthma Are you any of the following? Male over 45yrs? Postmenopausal Diabetic Do you have any joint problems, aches or pains we can aim to improve for you or any existing injuries we should be aware of?YesNoPlease SpecifyDo you smoke?YesNoAre you pregnant?YesNoDo you take any prescription medication?YesNoIf yes, please specifyWhat results do you wish to achieve? Reduce body fat Stress Management Sports Conditioning Rehabilitation Strength Training Reshaping Improve Muscle Tone Weight Loss Increase fitness Improve Flexibility Other Where do you want to achieve your results? Thighs Stomach Buttocks Chest Back Arms Shoulders Calves Lower Back Hips Waist Other When would you like to achieve these results? How many days a week do you wish to exercise? How long have you been thinking about it? What has kept you from starting sooner?Do you need help with any of the following? Motivation Gym Knowledge Accountability Nutrition Other Please state other: If you keep doing what you have been doing up until this point, do you think you are guaranteed to get the results you desire?YesNoIMPORTANT QUESTION: Are you genuinely SERIOUS about improving your health and fitness and achieving your results?YesNoOn a scale from 1 – 10 how important is it for you to achieve your results?12345678910Are you on Facebook?YesNoWould you like to be added to our facebook group?YesNoBy signing this document, you agree that the information provided is accurate to the best of your knowledge.SignatureTodays Date MM slash DD slash YYYY Privacy Policy Terms & Conditions Designed by - Karine Marie-Website Designer