Just Exercise Program Form

Full Name:  

E-mail:  

DOB:  

Height (cm):  

Weight (KG):  

   Select your current activity level: Sedentary Lightly Active Moderately Active Very Active

When was the last time you did exercise or played sport?: This Week Last Fortnight Last Month 2 - 6 Months Ago 6 - 12 months ago 1 - 5 years ago 5 + years

What was the exercise or sport ? please specify:  

Specify Goal 1 (eg. lose 5kg): 

Specify Goal 2: 

Specify Goal 3: 

             Specify Goal 4: 

Specify Goal 5: 

Any any specific time frame or deadline to achieve goals? e.g. wedding in 3 months:

Do you have any physical limitations such as an injury, disabilities or medical conditions that require medication?  if Yes please specify:  

Do you have access to equipment? please specify:

Do you want to target any specific body areas?: