12 Week Transformation Questionnaire

About you

First name *

Last name *

Email address *

Phone

Date of birth *

Day

Month

Year

Street Address

City

Postcode

Country

Weight (in kg) *

Height (in metres) *

Age *

What's your gender? *

MaleFemalePrefer not to say

Lifestyle

Occupation *

How Active Is Your Job? *

Rate your stress levels from 1 to 10 *

Tell us a bit about this. *

Health and behaviour history

Are you pregnant? *YesNo

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

If yes, how long ago?

Are you breastfeeding? *YesNoPlease note that this programme may have an effect on the quality of your milk.

Did you have any complications with your pregnancy or after birth, such as a prolapse or separation of stomach wall (Diastasis Recti) *Please also include what type of birth you had - natural/C-section

Are you going through perimenopause? *

YesNo

If yes, please tell us a little about your symptoms and how these are being managed *

Are you taking HRT or other hormones? *

Do you have high, low or normal Blood Pressure? *Please expand

Do you have high, low or normal Cholesterol? *Please expand

Have you had any surgery recently? If yes what for? *

Do you have any injuries that would prevent you from certain exercises (such as high impact exercises) *

Are you currently taking any medication? If yes, what is it and what are you taking for? *

Would you say you are an all-or-nothing person? *

YesNoSometimes

If yes, please elaborate

Have you ever had obsessive behaviours, mostly when dieting? *

YesNo

If yes, please tell us more. *

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

Do you/have you ever taken medication for these symptoms?Please give us details

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

What motivates you? *

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 yes, what do you do and how often?

If not, when did you last exercise?

Are you a gym member? *

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? *

YesNo

If yes, which type/s of diet? *

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

YesNo

If yes, please expand. *

Have you ever had an eating disorder? *

Have you ever lost your period? *

YesNo

What has worked well for you when dieting in the past? *

What hasn't worked as well when dieting? *

Have you ever tracked your calorie intake before? *

YesNo

If yes, how did you find it? *

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 explain either way

What is keeping you from achieving your nutrition goals? *i.e., motivation, lack of knowledge

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

On a scale of 1-10 how important is this change for you?10 being the most important!

Terms and conditions *

By checking this box, I agree to the terms set forward of ace 12 week transformation Programme and agree to all the terms laid out in the Terms and Conditions for this Programme.

Physical Activity Readiness Questionnaire (PAR-Q)

If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor. Common sense is your best guide when answering these questions please read carefully and answer each one honestly: check YES or NO.

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 yes, 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.

Full name *

GDPR *Yes, I agree with the privacy policy and terms and conditions.

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

How did you find out about aceTRANSFORM?