12 Week Transformation Questionnaire

About you

First Name *

Last name *

Email Address *

Mobile number *

Date of birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Weight (in Kg) *

Height (in meters) *

Age *

What's your gender? *MaleFemalePrefer not to say

Lifestyle

What's your occupation?

How active is your job?

Rate your stress levels from 1 to 10

Please tell us a bit about this and how you usually cope with stress

Health & Behaviour History

Are you pregnant? *YesNo

Have you had a baby in the past 6 months? *YesNo

Are you breastfeeding? *YesNo

Please tell us a bit more about this - how old is your baby? How many times are you breastfeeding daily on average? *

Any complications during/after pregnancy? *

Are you going through perimenopause/menopause? *YesNo

Describe your symptoms and management strategy *

Are you taking HRT or other hormones? *

What's your blood pressure like? *

What's your cholesterol like? *

Have you had any surgeries recently? *

Have you got any injuries that limit your ability to exercise? *

Are you currently on any medications? If so, please tell us a bit about which medications and why *

Do you consider yourself an all-or-nothing person?YesNo

Do you have any history of obsessive behaviours, especially around dieting?YesNo

Do you/have you ever suffered from any mental health conditions, such as depression, anxiety, OCD, stress related etc. *

Do you/have you ever taken medication for these symptoms?

How many hours sleep do you get a night? Do you feel like you get quality sleep and wake up feeling well rested?

Exercise history

Have you ever tried a home workout programme before? If so what did you do and how did you find it? *

Do you currently exercise? *YesNo

If not, when did you last exercise?

Are you a gym member?YesNo

Are there any physical limitations that would inhibit or limit your participation in an exercise programme? If yes, please tell us why *

What is keeping you from achieving your current fitness goals?

Dieting history

How would you describe your relationship with food?

Are you or have you ever been on a diet?

Do you consider yourself as an emotional and/or binge eater?

Have you ever had an eating disorder?

Have you ever lost your period?

Have you ever tracked your calorie intake?

Nutrition

Do you have any allergies?

Do you have any food intolerances?

What are your goals?

Do you have any dislikes or dietary requirements?

Have you lost or gained weight recently?

PLEASE NOTE THAT WE NEED PARTICIPANTS TO PUT IN 100% TO ACHIEVE THE BEST POSSIBLE RESULTS *Got it!

On a scale of 1-10 how important is this change for you? *

Physical Activity Readiness Questionnaire (PAR-Q)

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

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

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

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

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? *YesNo

Is your doctor currently prescribing medication? (for your blood pressure, heart condition etc?) *YesNo

Do you suffer from Asthma? *YesNo

Do you suffer from Epilepsy? *YesNo

Do you know of any other reason why you should not do physical activity? *YesNo

If you answered yes to any of the above questions, please comment. *

Signed *In consideration of being able to take part in exercise and physical activity organised by ace lifestyle, I acknowledge that I am physically fit for participating in ace lifestyle activities. I agree to abide by all verbal and written notices regarding safety whilst exercising with ace lifestyle. ace lifestyle shall not be liable for any injury or death I may suffer in these activities.

Signature

If you are doing the programme with someone else, please provide their name/s to be put in the same group

How did you hear about aceTRANSFORM?