PROGRAM SETUP QUESTIONNAIRE

Now you are onboard we need to create a tailored program based around your current activities and habits, this will ensure the program works for you and you keep motivated.

Please complete the questions below and your program will be ready very shortly!

First name*

Last name*

Age*

Weight in KG*

Height in CM*

Daily Activity Level - Select one that suits you best *

Sedentary - Seated work with some need for occasional walking or standing. Little to no strenuous leisure activities.

Moderate - Predominantly standing or walking work with significant amounts of strenuous leisure activity.

High - Heavy occupational work or significant strenuous leisure activities.

Detail any activity/training you do currently and frequency (walking Monday, gym Tuesday, classes Wednesday etc.)*

Do you have any specific goals you want to achieve? (wedding, holiday, photo shoot, weight loss etc.) Please add the date you need/want to achieve the goal by

Please provide foods you don't like/can't eat (allergies)

Please provide any supplements you are currently taking

Provide next of kin*

Provide next of kin relationship*

Provide next of kin contact number*

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?*

Yes

Do you feel pain in your chest when you do physical exercise?*

Yes

In the past month, have you had chest pain when you were not doing physical activity?*

Yes

Do you lose balance because of dizziness or do you ever lose consciousness?*

Yes

Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in your physical activity?*

Yes

Is your doctor prescribing medication for your blood pressure or heart condition?*

Yes

Have you or any of your family members suffered from diabetes?*

Yes

Do you have any allergies?*

Yes

Do you know any other reason why you should not take part in physical activity?*

Yes

If you have said yes to the above please provide commentary

1-2-1 Terms & Conditions

Online Terms & Conditions

ICO Registration - ZB698051

CIMPSA Registration - C005419

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PROGRAM SETUP QUESTIONNAIRE

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