Welcome!

Welcome!

Congrats on getting started with the Feel Energised Community! Please fill in this health & lifestyle form to get started.
First Name *
Last Name *
Email *
Best Contact Number *
Personal History
Have you or your direct family had any of the following (please select)

Diabetes High Blood Pressure Asthma High Cholestrol Heart Problems Stroke Arthritis Osteoporosis
Do you smoke?

Yes No
If you stopped smoking, how long ago did you stop?
Medications
Do you take any pills, medicines, medications or supplements? If yes, please describe.
Injury Profile
Do you have any injuries? - If yes please specify, eg left knee, had surgery. Still gives me pain when I run long distance.
Is there anything else that may affect you exercising?
A little bit about your family...

It's helpful to know how many children you have, their age(s), type of delivery and if you had any issues or complications.
How many children do you have? (Name, Age)
Type of delivery? (All Children)
Were there any complications?
Did or do you still have Diastasis Recti?
Did you have Pubis Symphasis Dsyfunction?
If you have a child under 12 months...
Has your doctor/midwife said it's okay to start exercising?
Are you breastfeeding?
Did you participate in any exercise before or during pregnancy?
Exercise Preferences
If you are currently exercising... What activities are you doing?
If you have previously exercised... What activities did you do?
On average, how many times a week do you exercise?
Food Preferences
What time do you wake up on weekdays (workdays)?
What time will you eat for the first time on these days?
What will you usually eat?
What time will you eat for the second time on these days?
What will you usually eat?
What time will you eat LUNCH?
What will you usually eat?
What time will you eat your afternoon snack?
What will you usually eat?
What time will you eat DINNER?
What will you usually eat?
What time will you eat your evening snack?
What will you usually eat?
What time do you go to sleep on weekdays (workdays)?
How much water do you drink?
Do you drink caffeinated drinks? If yes, how often?
Do you drink alcohol? If yes, how often?
On a scale of 1 -10, how are your energy levels in the day?
Your Goals...
What is your 6 Week Goal?
What is your 6 Month Goal?
Commitment
How important to you is it that you achieve the goals above? 1 being of little, 10 being of great
What areas are you willing to work on to achieve these goals?

Exercise Nutrition Stress Managment Mindset
Any other information you would like to share?

Payment Details *

Master Membership ( $ 21.99 NZD for each 1 months )

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Master Membership
You'll get an All Access Pass to the Feel Energised App, Coaching Calls and an invitation to join our Feel Energised Community (Facebook Group).
Your membership will auto-renew monthly. You cancel cancel at anytime by emailing me at debs.fitzpatrick@outlook.com.
Optional Extras (please tick if interested)

6x Small Group Sessions (Nelson Based Members) $60 30min One on One Session $30 60min One on One Session $60 Online One on One Session from $30
Client confidentiality
We do not share your information with any other individuals, companies or websites. All information included in your questionnaire is held strictly confidential.

Informed consent
I hereby acknowledge that the information provided above regarding my health is, to the best of my knowledge, correct. I will inform you immediately if there are any changes to my health status.

Disclaimer
I acknowledge that participation in physical activity carries a risk and I accept all responsibility for that risk.
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Welcome!

Personal History

Medications

Injury Profile

A little bit about your family...

If you have a child under 12 months...

Exercise Preferences

Food Preferences

Your Goals...

Commitment