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*

How did you find out about SIMplyFIT?*

Your goals

What do you want to achieve?

Check all that apply

Other - what do you want to achieve?

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 are you currently doing?

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 (tick box to submit assessment)

Email

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