Client Consultation Form This information is sent in the strictest confidence to our Head Coach, Dan Roberts. We will get in touch within 24 hours. Name First Last Date of birthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email OccupationMobile numberHeightWeightEmergency contact name & mobile How did you hear of Dan Roberts™ A personal recommendation TV / Newspaper / Magazine Interview Public event / talk Google search Instagram (@teamdanroberts) Instagram (@Methodology_x) Facebook Advertisement Current/old customer What injuries do you have?Do you suffer from any of the following? ME High blood pressure Low blood pressure Diabetes Disordered eating BDD ADHD Raised cholesterol Anxiety Liver or Kidney conditions Digestive problems Any heart condition Epilepsy Hernia Osteoporosis Arthritis Asthma Cramps Muscular pains Do you smoke?NoOccasionally40+ a weekHow much do you drink?Occasionally10+ units most weeks25+ units most weeksWhat medications are you on? Do you have any infectious diseases?NoYesHave you been recently hospitalized?NoYesHave you recently had surgery?NoYesAre you pregnant?NoYesWaiver of Liability: Please scroll through fully and TYPE your name at the end.*We assume no liability for persons injured following our exercise or nutrition advice. In addition any Martial Arts or combat training is only available to those who waive all liability to any accidents or injury. If any medical or other conditions arise that could affect your training with us, you shall let us know immediately by email. If you have any doubts, please consult your doctor prior to physical activity. All exercise, nutritional and well-being advice given to you by any persons directly associated with Dan Roberts, Dan Roberts Training Ltd & Dan Roberts Enterprises Ltd is taken at your own risk. By typing your name and today's date after this statement you agree by these terms. This is required. Please type your full name and date right here....DELETE THIS AND TYPE YOUR NAME & DATEPlease read and sign aboveDid you TYPE YOUR NAME and DATE the liability waiver above?* Yes Why contact us now?Which of your goals can we potentially help you with?Why are these goals important to you?What other fitness and wellbeing goals do you have?What training do you currently do?If you would like us to contact your last trainer, please give details.What are your expectations?Which exercises/activities do you love doing and why?Do you want help with nutrition?No thank youMaybeDefinitelyDo you want help with stress?No thank youMaybeDefinitelyDo you want help with body image?No thank youMaybeDefinitelyIs there anything else we should know?Do you know what coach you want? Dan Senior Coach: £125-165 per 60m Junior Personal Trainer: £75-100 per 60m Specialist Coach A mix of coaches I don't mind. Up to you! How often do you want to train? I want an intensive programme 5 x per week 4 x per week 3 x per week less than 3 times a week I don't know Are you interested in any of our specialist services? Movie Role Prep Fashion Model Conditioning Pro Athlete Consulting 100 Day Transformation Programme 12 month Revolution Package Martial Arts / Combat instruction Our luxury 1-2-1 Retreats in Miami International: We travel to/with you Life Coaching Post Natal programme Where are your preferred coaching locations (London) Your Home or Royal Park (Zones 1-2) The Kensingon Studio, High Street Kensington Ham Yard Hotel, Piccadilly Shangri-La Hotel, The Shard (GUESTS ONLY) Athletics Track, Battersea Park Where is your preferred coaching location (New York) Outside Your home Private studio Do you know anyone else who would be interested in working with us?What is your availability to train?When would you like to have your face-to-face consultation with Dan?These are held at The Groucho Club, Soho. (London) Telephone/ Skype consultations are available to our international clientele.Do you have any specific additional questions for Dan?