Slim Brother
Please choose your requirement (class/course/coaching)
Online Course - 199 GBP
Class Derby - 20 GBP Per Month
Class Burton - 20 GBP Per Month
Title
Mr
Miss
Mrs
Ms
Other
First name and family name
Any name you prefer to be called
Address and Postcode
Mobile telephone number
Next of kin name and telephone number
Email Address
Retype Email Address
Date of birth
Weight (stone)
Height (feet)
Waist and hip size (inch)
(Females only) Dress size
Occupation
Marital status
Single
Married
Engaged
Living with Partner
In a relationship
Other
Number of children and ages, if any
What is your attitude to food
Why do you need Slim Brothers help
Favourite Food
Favourite Drink
What did you eat yesterday
Where do you normally shop for food?
ADSA
Sainsburys
Tesco
Marks & Spencer
Waitrose
Somerfield
Morrisons
Iceland
Farm Foods
Aldi
Lidl
Netto
Market/Farm
Organic Farm
Other
None - someone else does it for me
None - eat at takeaway/restaurants
Diets tried before
Weight Watchers
Slimming World
Rosemary Conley
Slim Fast
Atkins
Metabolic Type
Lighter Life
Other
None
Current exercise programme (30 minutes plus)
None
Sometimes
Weekly
Daily
What is your 8-week goal
Do you have any health conditions
Diabetes
Asthma
High Blood Pressure
Epilepsy
ME
MS
PWS
IBS
Bulimia
Recently had surgery
Taking medication
Pregnant or have been in the last 6 months
Other
Other health problem details (if any, and full details of any above conditions), any operations you've had and any medication you currently take
Do you have any special dietary requirements (vegetarian, vegan, nut allergy, etc)
Where did you first hear about us
Please tick below to confirm
I UNDERSTAND I SHOULD CONSULT MY DOCTOR BEFORE STARTING ANY NEW DIET, EXERCISE OR LIFESTYLE PLAN.
Please tick if applicable
I DO NOT want Slim Brother to send me slimming tips & news via SMS & email.
Digital Signature - Please write your full name
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