PERSONAL DETAILS First Name Last Name E-mail Address Date of Birth Occupation Phone EXERCISE HISTORY & ACTIVITY LEVEL How often do you currently exercise and how active is your lifestyle? Describe your previous habits? ACHIEVING YOUR HEALTH & FITNESS What are your main motives for beginning The Twelve fitness program? Do you have specific things you desire to achieve? ie run a marathon, to be fit enough to play with your children, improve my health issues. In regards to your current personal situation what are your current priorities whether it be career family health or other? INJURY HEALTH & SAFETY Do you have any injuries or Chronic (reoccurring) pain? If yes are you currently receiving treatment? CONTACT DETAILS OF HEALTH PRACTITIONER Medical ClearanceNote : if you answer yes to any of these below questions Informa Health and fitness advices you to seek medical advice before starting any fitness exercise program. Have you ever been told you have a heart condition?NoYes Do you experience chest pain or experience dizziness or a loss of consciousness during or after exercise?NoYes Do you take blood pressure lowering medication?NoYes Are you over the age of 65 and unaccustomed to exercise?NoYesYOUR TRAINING Select your level of interest in the following training types (Like =1 Impartial =3 Dislike =5) Cardio training or any kind of HIIT 12345 Weight Training 12345 Stretching 12345 Sports 12345 Walking 12345 Functional and core exercises 12345Within 24 hours your application will be reviewed and we will get back to you for further steps. By using this form you agree with the storage and handling of your data.