Contact Salisbury Personal Trainer

Contact Us

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	Personal
First Name*:
Last Name*:
Date of Birth:	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Gender:	Male  Female
Address 1:
Address 2:
City/Town:
County:
Postcode:
Tel:
E-mail*:
Retype E-mail*:
	How did you hear about me: Select Magazine Radio TV
	Weight Loss Information
1)	How much weight do you want to lose? 1 2 3 4 5 6+
2)	How much time are you expecting this to take to achieve?
3)	On a scale of 1 - 10, 10 being the most motivated how would you score yourself? 1 2 3 4 5 6 7 8 9 10
4)	Are you, or have you undergone treatment for depression? no yes
5)	Are you, or have you being treated for any eating disorders? no yes
6)	What have you tried in the past to lose weight?
7)	How successful where you?
8)	How soon would you like to get started on the Coach Me Slim & Trim® programme?
9)	What most appeals to you about the Coach Me Slim & Trim® programme?
	Health & Medical
1)	List any medical conditions you have:
2)	List any injuries you have:
3)	If you have injuries, how do the affect you?
	Personal Lifestyle
1)	What do you currently do to keep fit/healthy?
2)	How often? Regarding the previous question
3)	What would a typical day in your life entail?
4)	Why do you want to work with a weight loss coach and trainer?
5)	What do you think you will achieve in the next 90 days?
6)	What are you willing to do to make this happen?
7)	What things are you likely to say to yourself or use to get out of training or following your healthy eating plan?
8)	How did you hear about my services? word of mouth flyer newspaper ad car talk other
	Finally...
	Explain why you think you would be a good candidate for working with me and how will I get the best from you:
	Yes I would like to receive weight loss and fitness tips.
	Please enter the characters into the field

• Synergiselect Limited
• PO Box 1862
• Amesbury
• Salisbury
• Wiltshire
• SP4 7WA
• Tel: 01980 595 502
• Fax: 01980 595 502
• Email: info@salisburypersonaltrainer.co.uk


• Company registered in England & Wales
• Company Registration Number: 3850623