Membership Checkout

Membership Information

You have selected the In-Person Couples Classes membership level.

The price for membership is R 850.00 now and then R 550.00 per Month.

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Account Information

Username

Password

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First Name

Last Name

Email Address

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Full Name LEAVE THIS BLANK

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Personal Details

Please enter all your personal details below.

Title

Contact No

ID Number

Postal Address

Date of Birth

Age

Notes

Gender

Start Weight (kg)

Goal Weight

Height (cm)

Start BMI

Target BMI

Eating And Lifestyle Habits

Please add your eating and lifestyle habits. This will help us to create a personalised health and eating plan for you. Be as descriptive as possible.

Do you wake up tired?

Yes

Do you have energy loss during the day?

Yes

What do you eat & drink for breakfast?

What time do you have breakfast?

What do you eat for a mid- morning snack?

How many alcohol units do you drink per week?

What do you eat for lunch?

How many chocolates, chips & sweets do you eat per week?

What do you eat for a mid-after- noon snack?

How many cold drinks do you drink per week?

What do you eat for dinner?

What do you eat for an evening snack?

Do you take a multi vitamin?

Yes

What other supplements do you take?

How many cups of coffee / tea do you have per day?

Do you smoke? How many per day?

How long have you been smoking?

How much water do you drink (cups)?

Are you exercising, how much are you doing weekly?

Any food allergies

When did your struggle with weight start?

Think back what was going on in your life at that time?

If you have cycles of your weight going up and down, try to identify the triggers

Describe any significant events from your childhood- perhaps something a teacher, sibling or friend said or did – that implicated on the way you see yourself

What do you think about your body currently?

What are your feelings that go with what you described above? List them

NOTE: if changing a subscription it may take a minute or two to reflect. Please also login to your PayFast account to ensure the old subscription is cancelled.

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Membership Information

Account Information

Personal Details

Eating And Lifestyle Habits

Health Details