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Online Training Programme Signup

(What do I get when I sign up?)

Please take the time to complete the below form, which also includes a compulsory Health Screening form. On successful completion of this form you will have the opportunity to pay for your preferred training programme. Please note that you have not successfully signed up for our online training programmes until you have made payment.

Step 1: Complete the below informational and screening form

Please answer Yes or No to the following questions:

Do you have any medical conditions, are you presently undergoing any medical treatment or taking any medication?		Yes No

Have you had any medical conditions in the past or undergone any medical treatment?		Yes No

Has your physician been informed of your participation in this exercise programme?		Yes No

Are you or have you been pregnant in the last 4 months?		Yes No

What exercise do you currently take?

How often do you exercise?

Do you have or have you had in the past any of the following:

Heart problems, high blood pressure or coronary heart disease?		Yes No

Chest pains or stroke?		Yes No

Diabetes, asthma or epilepsy?		Yes No

High blood cholestrol?		Yes No

Family history of any medical conditions including heart problems under the age of 55?		Yes No

Advice from a physician not to exercies?		Yes No

Osteoporosis?		Yes No

Hernia?		Yes No

Musccular, joint or back pains or disorders?		Yes No

Recent surgery of any description within the last 6 months?		Yes No

Chronic illness or condition?		Yes No

Injuries related to exercise?		Yes No

Dizziness or Headaches?		Yes No

Cold Hands or feet?		Yes No

Allergies?		Yes No

Have you had any operations?		Yes No

Have you had any major childhood illnesses?		Yes No

How many units of alcohol do you drink per week?		Yes No

Do you smoke?		Yes No

If yes, how many (on average) per day?

Please rate the following on a scale of 1 to 6 (where 1 is low/poor and 6 is high/excellent):

Energy Levels:

Concentration:

Memory:

Sleep:

Digestion:

Bladder function:

Mental Attitude:

Please supply the following Health and Diet information:

Do you follow any special dietary practices (If Yes, Since when and for what reason)?

Do you take any food supplements (vitamins, minerals, herbs)?

Typical Daily Diet:

Breakfast:

Mid Morning:

Lunch:

Afternoon:

Evening Meal:

Training Programme:

Please note that you cannot sign-up for our online training programmes until you have successfully paid the associated fee. Payment is accepted via PayPal on the next screen.

Personalised Training Course - 1 month (€32) Personalised Training Course - 3 months (€85) Personalised Training Course - 6 months (€160) Personalised Training Course - 12 months (€300) Fitness Test (€32) Diet Consultation (€32)

Acknowledgement:

I acknowledge that, to the best of my knowledge, I am in good health and have no medical problems that would restrict my ability to participate in this exercise programme. I will inform you of any change in my health status or the development of any medical condition or the commencement of any medication, In consideration of the above acknowledgement and my participation in this exercise programme I hereby release Tony Matthews from all liability.

Name:

Date:

Tel No :

Email:

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