Lifestyle Coaching Consultation Form This information is sent in the strictest confidence to Dan Roberts. We will get in touch within 24 hours. Name First Last Date of birthMMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email OccupationMobile numberDate of BirthHeightWeightEmergency contact name & mobile Separate tags with commas How did you hear of Dan Roberts™ A personal recommendation TV / newspaper / magazine Public event / talk Google search Facebook Instagram (@TeanDanRoberts) Twitter, Pinterest or another social media page. Methodology X class Advertisement Current/old customer 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? No Occasionally 40+ a week How much do you drink? Occasionally 10+ units most weeks 25+ units most weeks How much do you usually sleep? Less than 5 hours 6-8 hours 9+ hours What medications are you on? Separate tags with commas Do you have any infectious diseases? No Yes Have you been recently hospitalized? No Yes Have you recently had surgery? No Yes Are you pregnant? No Yes Waiver 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 What prompted you to contact us?Are their specific goals you want help with?Why are these goals important to you?What are your expectations?Do you suffer from Stress? and how does this manifest?Is there anything else we should know?Have you worked with life coaches before?What was the experience like? What worked / didn't work?How do you want your sessions? Skype Facetime Telephone Do you have any specific questions for us?
