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Pre-Consultation Form
In order to undertake any service with Dean Zweck PT and Nutrition we ask all potential clients to complete the following Pre-Consultation Form, in detail, so we can get a better insight into you, your background and your goals.
We will endeavor to get back to you with our Service Brochure, which lists all of our services with associated costs within 1-3 working days. If required, we can also personally recommend a service based on your individual goals and budget…
Personal Details
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Indicates required field
Name
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First
Last
Age
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Email
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Phone Number
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Height
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Weight
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About you: (Lifestyle, Occupation - not your goals)
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What are you hobbies and social interests?
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Which of these goals are important to you?
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Lose body fat
Build Muscle
Get Stronger
Get Fitter
Performance Based
Other
Please expand on your goals below including ranking them in order of importance
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Your Current Diet
How many meals a day do you eat on average?
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Do you eat very similar meals each day or are they more varied/ erratic: (Please expand)
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Please give details below if possible on a typical day's food intake
Breakfast
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Snack
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Lunch
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Snack
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Dinner
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Snack
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Do you use any supplements/medication?
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Yes
No
Have you used any supplements/medication in the previous 12 months?
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Yes
No
If Yes, please give details here: (brand, quantity etc)
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Support
In very simple, practical terms, what is it that you need to do to achieve your goals? i.e. what can we do for you?
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The different services we offer vary in terms of the level of support, time and client effort required. To better help advise you on the most appropriate and effective service for your individual goals, please indicate the budget most applicable to your current situation.
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< £100
£100 - £200
£200 - £500
> £500
Please state your dietary requirements (i.e. any foods you can/will not eat):
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If we end up working together, what does success look like to you in 3 months, 6 months and 12 months?
3 months
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6 months
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12 months
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Have you previously sought dietary advice? If so, please expand
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Current Training/Exercise
Please give details about your current levels of exercise including time/type/intensity/frequency/preferences
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Movement preference #moSTYLE
When it comes to exercise, do you prefer?
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Structure
Freedom
Both
When it comes to exercise, do you prefer?
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Routine
Variety
Both
When it comes to your spare time, do you prefer activities that are more?
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Practical
Adventurous
Both
Females only
Please detail information relating to menstrual cycle length, frequency or if you are postmenopausal:
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Do you own the following? Check if you do
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Bathroom scales
Kitchen Scales
Where are you geographically based?
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Would you be willing to provide a testimonial and/or before and after photos (if applicable) for the website and/or social media?
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Yes
No
Do you have access to Skype/Facetime should your consultation need to be remote? (Face to face is located in Bury)
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Yes
No
How did you come across us? e.g. Newspaper, Magazine, TV, Google search, Personal referral etc (Please expand if possible)
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Thank you for taking the time to fill this in.
We look forward to working with you!
I agree to receiving marketing and promotional materials
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Home
Pre-Consultation Form
OCR Programme Application
OCRWelcome
Feedback
VIP Members Section
Music
Extras
Trainerize
Extra goodies
Freebies
Sample Recipes
Blog
Privacy Policy