New Client form New Client Form Welcome To kirstyredford.co.uk! Please Fill Out The Following Information Thoroughly So I Can Let You Know If You Are A Case I Can Accept And Help. Please Feel Free To Ask Any Questions If You Need Assistance. I Look Forward To Serving You! Name Address Email Birth Date Are you under a doctor’s medical supervision at this time? Yes No If Yes, for what? Are you in good health at the present time to the best of your knowledge? Yes No Are you taking any medications at the present time? Yes No If Yes, what medications? Do you take vitamin supplements? Yes No If Yes, what vitamins? History of high blood pressure? Yes No History of diabetes? Yes No History of frequent headaches or migraines? Yes No History of constipation? Yes No Surgeries? Yes No Current injuries? Yes No Do you have a family history of: Diabetes? Heart Disease? Cancer? Stroke? If Yes, Who? Height Current Weight Goal Weight When would you like to be at your desired weight? Why do you want to gain/ lose weight? (Health Benefit? Appearance?) Please explain thoroughly: What has been your maximum weight (non-pregnant) and when? Have you tried other weight courses? Yes No If yes, which ones? Were you successful with it / were you able to keep the weight off/on? How often do you eat out? How often do you eat “fast foods”? Food allergies? Food dislikes? Food cravings? Do you drink coffee or tea? Do you drink pop / soft drinks? Do you use sugar substitutes? What are your worst food habits? Snack habits When there is increased stress in your life, do you tend to eat more or less? Typical Breakfast Typical Lunch Typical Dinner Describe your energy level? Activity Level Inactive Light Activity Moderate Activity Heavy Activity Vigorous Activity Is there any exercise you cannot do? On a scale of 1 to 10 with 10 being MOST committed, how committed are you to taking action and making a change in your life today? 1 2 3 4 5 6 7 8 9 10 Preferred method of contact Telephone Email Acceptance I agree to Kirsty Contacting me using the details I have supplied within this form. ( For response purposes only) How Were You Referred To Me Commit Now!