Personal Information

Name and last Name:

Date of Birth:

Weight:

Lenght:

Job title:

Contact details

Emailadress:

Phonenumber:

Adress:

Postal code & town:

Goals & Sport History

In the past 3 months, how often have you participated in sports (or any other exercise that required sweating)?
not at all, or less then 1 time a week1 to 2 times per week3 or more per week

Which sports did you practise and how long?

My goal(s) are: (more options possible)
Improve fitnessLose weightGain MuscleGain weightHealthy lifestyle

How many hours per week would you like to exercise?

Do you have a watch with a heart rate monitor??
YesNo

Which of the following activities appeal to you? (Multiple possible)
SwimmingCyclingWalking/jogging/runningSkatingMuscle strengthening exercisesHIT (High Intensity Training)

Which activities do you NOT find interesting?

Medical information

Do you get a painful and pressing sensation in the chest when exercising?
YesNo

Do you experience sudden dizziness
YesNo

Have you had a brain hemorrhage in the past year?
YesNo

Have you had a heart attack in the past year?
YesNo

Have you had surgery in the past year?
YesNo

Are you taking any medications?
YesNo

Do you suffer from an illness where the attending physician has advised you that you should be careful with (heavy) physical exercise or advised against exercising?
YesNo

Have you ever had an exercise test?
YesNo

Have you had an injury or injury?
YesNo

Have you ever had a bone broken/dislocated?
YesNo

Are there any other physical or mental problems that should be considered in training?
YesNo

If one or more of the above answers was yes, enter more information here: