NAME*

MR MS MRS

ADDRESS

TOWN / CITY

COUNTY / STATE

COUNTRY

POST CODE / ZIP

TELEPHONE*

E-MAIL ADDRESS*

OCCUPATION*

BRIEF JOB DESCRIPTION

WEIGHT*

KILOS POUNDS STONES

AGE*

HAVE YOU HAD ANY OF THE FOLLOWING ?

PLEASE TICK RELEVANT BOXES

RECENT SURGERY 

IMMEDIATE FAMILY MEMBER SUFFERED HEART ATTACK BEFORE AGE 50 

If you have answered yes to any of these questions or are over 35 years old, it is wise to seek a doctor’s advice before a change of "diet" or beginning an exercise programme. The doctor should take your pulse, temperature and blood pressure.

Please enter below your specific details. These are confidential.

What are your goals?

weight/fat loss muscle with fat loss muscle gain

note:

 If you are slightly overweight it is best to select weight / fat loss to begin with.

YOUR HEIGHT

Metres   or    Feet

ACTIVITY LEVELS AT HOME*

please select Not very active Moderately Active Very Active

ACTIVITY LEVELS AT WORK*

please select Not very active Moderately Active Very Active

ACTIVITY LEVELS AT PLAY*

please select Not very active Moderately Active Very Active

WILL POWER*

please select Not strong willed Moderately strong willed Very strong willed

MEALS / DAY*

4 5 6

MILK PER DAY FOR CEREAL TEA etc.*

0 pint 1/4 pint 1/2 pint 3/4 pint 1 pint

PREFERRED METHOD OF WEIGHING FOODS TO BEGIN WITH.*

Ounces Grams

ADDITIONAL COMMENTS