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LIFESTYLE
EVALUATION FORM
Welcome!
After submitting this form you will be contacted by one of our certified personal coaches for a free try-out session. Congratulations for taking the first step towards a more active and FUNctional lifestyle!
#youarefunctional
Where did you hear about us??
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Brochure/flyer
Word of mouth
Infosession
Website
Social Media
Referral of a Coach (please specifiy):
Referral of a Coach (please specifiy):
Name, Surname
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🛈
E-mail address
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Telephone/GSM
*
Location
*
Postcode
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Year of Birth
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Coach of preference
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Amsterdam (Evodie Koolstra)
Antwerpen
Bilzen (Jeroen Oeyen)
Brussels (David Verstraeten)
Diest (Kenneth Masco)
Heist-op-den-Berg (Hans Van Den Brande)
Herselt (Maarten Gybels)
Leuven (Trui de Boitselier)
Lille (Max Icardi)
Nijlen (Ellen Van Poecke)
Rotterdam (Make a Move)
Tremelo (Thijs Ghekiere)
Turnhout (Pierre Antonissen)
Vosselaar (Pieter Segers)
Borsbeek (Christoph Strijbos)
Borsbeek (Hanna Mariën)
Kortrijk (Justin Couturon)
Buizingen (Lars Maesfrancx)
Winksele (Jan Craenen)
Andere
For corporate programs only. Please choose your company from the list:
Mercedes Benz
ING
Stad Turnhout
eTheRNA
Why are you interested in Functional Training? Please check all that apply..
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Reduce body fat
Increase muscle tone
Improve your health
Reduce stress
Design a more advanced program
Nutrition Education
Start becoming active
Fun and motivation
Sport specific training
Other (please specify)
Other (please specify)
LIFESTYLE
RELATED QUESTIONS
1. Do you smoke?
N0
YES. How many cigarettes/day?
YES. How many cigarettes/day?
2. Do you drink alcoholic beverages?
Never
On special occasions
Regularly with meals (how many glasses?____)
Regularly with meals (how many glasses?____)
3.How many hours do you normally sleep at night? ?
4.Describe your job:
Sedentary
Active
Physically Demanding
5. On a scale of 1-10, how would you rate your current stress level? (1 - very low)
1
2
3
4
5
6
7
8
9
10
6. List your 3 main sources of negative stress:
1: 2: 3:
7. Is anyone in your family overweight?
Mother
Father
Brother(s)/Sister(s)
Grandparent(s)
8. Were you overweight as a child?
YES
NO
If yes, at what age(s)?_______
If yes, at what age(s)?_______
FITNESS
HISTORY
1. When were you in the best shape of your life?
2. Have you been exercising consistently for the past 3 months?
YES
NO
If NO, why not?
If NO, why not?
3. When did you first start thinking about becoming more active?
4. What has prevented your from reaching your fitness goals in the past?
5. Have you had major injuries in the past? Do you still suffer from it?
5. On a scale of 1-10, how would you rate your present fitness level (1=Worst 10=Best)?
1
2
3
4
5
6
7
8
9
10
NUTRITION
RELATED QUESTIONS
1.On a scale of 1-10, how would you rate your Nutrition (1=very poor 10=excellent)?
1
2
3
4
5
6
7
8
9
10
2. How many times a day do you usually eat (including snacks)?
<3
3
4-6
>6
3. Do you often skip meals?
NO
If YES, why?
If YES, why?
4. Do you eat breakfast?
YES
If NOT, why?
If NOT, why?
5. Do you eat late at night?
Sometimes
Often
Never
6. What activities do you engage in while eating? (TV, reading etc)
7. How many litres of water do you consume daily?
<0,5
1-2
>2
I don't know
8. Do you feel drops in your energy levels throughout the day?
NO
If YES, when?
If YES, when?
9. Do you know how many calories you eat per day?
N0
If YES, how many?
If YES, how many?
10. Have you been dieting in the past?
NO
If YES, what were the results (short/long term)?
If YES, what were the results (short/long term)?
11. Besides when you're hungry, do you also eat because you feel...
Bored
Social
Stressed
Tired
Depressed
Happy
Nervous
Other
Other
12. List 3 areas of your Nutrition you would like to improve:
1: 2: 3:
13. Do you eat past the point of fullness?
Never
Sometimes
If OFTEN, why?
If OFTEN, why?
EXERCISE
RELATED QUESTIONS
1. How often do you take part in physical activity? (Minimum 30' mins)
Never
1-2 times/week
3-4 times/week
5-7 times/week
2. If your participation is lower than you would like it to be, what are the reasons?
Lack of Interest
Illness/Injury
Lack of Time
Lack of Motivation
Other
Other
4. Which activities are you currently engaged in?
Activity
# times/week
average duration
easy/moderate/intense
1.
Activity
# times/week
average duration
easy/moderate/intense
2.
Activity
# times/week
average duration
easy/moderate/intense
3.
Activity
# times/week
average duration
easy/moderate/intense
4.
Activity
# times/week
average duration
easy/moderate/intense
5.
Activity
# times/week
average duration
easy/moderate/intense
GOAL SETTING
In achieving your goals, we must first define them to create a blueprint for success
1. Please list in order of priority 3 fitness-based goals you would like to achieve over the next 3-6 months?
1: 2: 3:
2. How will you feel once you’ve achieved these goals? Be specific
3. How can your personal trainer help you in achieving your fitness goals?
4. Which support do you think you will receive from your family/spouse/friends/colleagues...?
5. Outline any obstacles, potential actions, behaviours or activities that could limit your progress towards accomplishing your goals (i.e. not training consistently, upcoming vacation, busy season at work, not following the program, allowing other responsibilities to become a priority over exercise etc.).
6. Outline 3 methods you will think to incorporate in order to overcome these obstacles:
1: 2: 3:
7. Realistically, how often (times/week) do you think you should exercise to reach your goal(s)?
1
2
3
4
5
6
7
Thanks for answering!
Yur personal data are sefe with us.
We appreciate your trust in us and therefore we guarantee that we will treat these information with the maximum care and not share/sell them in ANY case to third parties.
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Kind regards from all the Coaches of the Functional Training Netwerk!
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