Registration Form

  • Please complete the form below before attending a class, course or to book a one to one coaching session (exercise only participants - you do not have to fill in the nutrition questions if you do not wish, however it maybe helpful for your personal development)
  • Class members: If you prefer you can > click here to download a printable form and bring it along to the session with you
  • To view where one to one coaching is currently available > click here
  • Jody will email you within 48-hours to confirm the booking and if applicable one to one date.
Please choose your requirement (class/course registration or one to one coaching booking)
Title Mr
 Miss
 Mrs
 Ms
 Other
First name and family name
Any name you prefer to be called
Address and Postcode
Mobile telephone number
Home telephone number
Work telephone number
Next of kin name and telephone number
Email Address
Retype Email Address
Date of birth
Age
Weight (stone)
Height (feet)
Waist size (inch)
Occupation
Marital status
Number of children and ages, if any
Religion
What is your attitude to food
Why do you want to improve your health
Favourite Food
Favourite Drink
Please write down what you would normally eat and drink on a typical day for Breakfast, Lunch and Dinner, plus snacks and drinks (not a "bad" or "good" day)
Where do you normally shop for food? ADSA
 Sainsburys
 Tesco
 Marks & Spencer
 Waitrose
 Somerfield
 Morrisons
 Iceland
 Farm Foods
 Aldi
 Lidl
 Netto
 Market/Farm
 Organic Farm
 Other
 None - someone else does it for me
 None - eat at takeaway/restaurants
Diets tried before Weight Watchers
 Slimming World
 Rosemary Conley
 Slim Fast
 Atkins
 Metabolic Type
 Lighter Life
 Other
 None
Current exercise programme (30 minutes plus) None
 Sometimes
 Weekly
 Daily
What are your short term and long term goals
Do you have any health conditions Diabetes
 Asthma
 High Blood Pressure
 Epilepsy
 ME
 MS
 PWS
 IBS
 Bulimia
 Recently had surgery
 Taking medication
 Pregnant or have been in the last 6 months
 Other
Other health problems details (if any, and full details of any above conditions) and any medication you currently take
Doctors name and address (for reference)
Do you have any special dietary requirements (vegetarian, vegan, nut allergy, etc)
Where did you first hear about us
Please tick below to agree with the statement I UNDERSTAND I SHOULD CONSULT MY DOCTOR BEFORE STARTING ANY NEW DIET, EXERCISE OR LIFESTYLE PLAN