Thank you for putting your health and fitness first. I want you to be totally honest when answering the below questions. The only way to improve on something, is to know what needs improving.

Please complete the form below – all details and answers will be kept confidential

How would you rate your energy levels?

no energy

little energy

enough energy

lots of energy

* Waist Measurement (cm)

Remember to measure across your belly button and around your back

* Chest Measurement (cm)

Remember to run the measuring tape or string across your nipple line and around your upper back

On a scale of 1-5 (5 being totally stressed), how would you rate your stress levels?

1

2

3

4

5

Is it quality, undisturbed sleep?

yes

no

* Personal Details

First

Last

How many hours per night do you sleep? 5-7 7-9 more than 9