Initial Assessment - SIMplyFIT Perth

your information

name*

first last

date of birth*

gender*

email*

phone*

how do you want me to stay in touch?*

emergency contact name*

emergency contact phone*

your goals

what do you want?

check all that apply

other - what do you want?

list all of your concerns about your health, eating habits, fitness and/or body

out of the above concerns, which one feels most important/urgent?

why?

what are you prepared to do to work towards your goals?

approximately how many hours a week do you do other types of physical activity?*

e.g. housework walking to work or school, home repairs, gardening

what other types of movement and/or activities do you do?

your current health

have you been diagnosed (currently or in the past) with any significant medical condition(s) and/or injuries?*

Yes
No

right now, do you have any specific health concerns, such as illnesses, pain and/or injuries?*

Yes
No

right now are you taking any medications, either over-the-counter or prescription?*

Yes
No

disclaimer*

I accept that it is my responsibility to work directly with my health care provider before, during and after seeking nutrition and/or fitness consultation.

I accept (Accept to submit assesment)

Email

This field is for validation purposes and should be left unchanged.