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12 Week Transformation Questionnaire
About you
First name
*
Last name
*
Email address
*
Phone
Date of birth
*
Day
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Month
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Year
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2019
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1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
Street Address
City
Postcode
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Australia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cabo Verde
Cayman Islands
Central African Republic
Chad
Chile
China, People's Republic of
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
France, Metropolitan
French Guiana
French Polynesia
French South Territories
Gabon
Gambia
Georgia
Germany
Guernsey
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Island
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Johnston Island
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
North Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion Island
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
Saint Helena
Saint Pierre & Miquelon
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and South Sandwich
Spain
Sri Lanka
Stateless Persons
Sudan
Sudan, South
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan, Republic of China
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
US Minor Outlying Islands
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna Islands
Western Sahara
Yemen Arab Rep.
Yemen Democratic
Zambia
Zimbabwe
Weight (in kg)
*
Height (in metres)
*
Age
*
What's your gender?
*
Male
Female
Prefer not to say
Lifestyle
Occupation
*
How Active Is Your Job?
*
Select one...
Extremely
Very
Quite
Not at all
Rate your stress levels from 1 to 10
*
Tell us a bit about this.
*
Health and behaviour history
Are you pregnant?
*
Yes
No
Have you had a baby in the last 6 months?
*
Yes
No
If yes, how long ago?
Are you breastfeeding?
*
Yes
No
Please 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?
*
Yes
No
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?
*
Yes
No
Sometimes
If yes, please elaborate
Have you ever had obsessive behaviours, mostly when dieting?
*
Yes
No
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?
Yes
No
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?
*
Yes
No
If yes, which type/s of diet?
*
Do you consider yourself as an emotional and/or binge eater?
*
Yes
No
If yes, please expand.
*
Have you ever had an eating disorder?
*
Have you ever lost your period?
*
Yes
No
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?
*
Yes
No
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 RESULTS
Got it!
On a scale of 1-10 how important is this change for you?
1
2
3
4
5
6
7
8
9
10
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?
*
Yes
No
Do you feel pain in your chest when you do physical activity?
*
Yes
No
In the past month, have you had a chest pain when you were not doing physical activity?
*
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
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?
*
Yes
No
Is your doctor currently prescribing medication? (for your blood pressure, heart condition etc?)
*
Yes
No
Do you suffer from Asthma?
*
Yes
No
Do you suffer from Epilepsy?
*
Yes
No
Do you know of any other reason why you should not do physical activity?
*
Yes
No
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?
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