Who are you?

I would like to ask you to fill out the following form to gain insight into your motivations for exercising and preparing for workouts effectively. The information will not be shared with any third person.

Please complete this form prior to the assessment so I can include the information during this appointment

    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:

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