Personal Details:

First Name:

Last Name:

E-mail:

Phone:

Mailing Address:

Date of Birth:

Sex:
Male Female

Height:

Weight:

 

Goals

Please choose what you hope to achieve from your program
Reduce body fat
Improve aerobic fitness (heart/lung fitness)
Improve muscle definition
Improve overall fitness
Generally tone up
Reduce stress levels

Other:

What part of your body would you like to concentrate on:
(e.g.. buttock, chest, stomach. . .)

Do you have any home gym equipment?
Yes, I have:

Exercise History :

When was the last time you exercised regularly?
Never (if never, go to next section)
Approximately ago.

What type of exercise?


Frequency of exercise (times per week):
Once a week.
Twice a week
Three times a week
Four times per week
Almost every day

Intensity of exercise:
Hard
Medium
Light

Health Questions:

Have you had or do you have:
Arthritis
Asthma
Neck pain
Back pain
Knee pain
Hernia
Any heart condition
Any Chronic illness
High blood pressure>140/90
Raised cholesterol
Any other muscle or joint pains?

Are you on any prescribed medication?
No
Yes

Are you pregnant?
No
Yes:

If you answered yes to any of the above questions please describe in detail.

 

It is recommended that
all males over 35 and females over 40 years of age should have a medical assesment including an exercise ECG and cholestoral / lipid count.

 

Payment Details
(Please choose how long you would like to join and your preferred payment method)

Yes, I want to sign up for:

Note: All amounts are listed in Australian Dollars.

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6 Week Fat Loss Accelerator Program $197 - (6 Week - Day By Day, Week by Week Diet & Exercise Plan to Help You Get in-shape Fast!)
Easy Payment plan $80 per month x 3

12 Weeks for $397 + FREE Crosstrainer + FREE bonus month..
Easy payment Plan $150 per month x 3

Your prefered method of payment:

None Selected Visa MasterCard Amex
Card No.:

Exp. Date:

Amex Id No.:

Card Holders Name:

Healthy Shopping Guide 40 page booklet to help you make the best food choices when shopping. $11.00 YES, I would like a Healthy Shopping Guide to be added to my E-Fitness Registration.

Telephone Support For additional support and motivation- $15 per week YES, I would like Telephone support.

Get Fit Smart Fitness Solutions + workout diary $14.95 + P&H YES, I would like to purchase the book.