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Check Up - Intake form
Start of your dream physique
Please fill out the form below as specifically as possible.
Full name
(Vereist)
First + last name
E-mailadres
Phone number
What is your address?
Sex?
Men
Woman
What is your age?
DD dash MM dash JJJJ
What is your goal? Be as specific as possible
Your starting weight
Length
How would you describe the intensity of your work?
Light work, mainly sedentary (e.g. office work, computer work)
Average work, occasional sitting and standing (e.g. sales)
Heavy work, mainly standing and/or walking (e.g. catering, construction)
Very heavy work, constantly moving and/or lifting (e.g. plasterer, mover)
How long have you been training? Are you a beginner/intermediate/experienced?
Beginner
Average
Experienced
How much stress do you suffer from? Give a score from 1 to 10.
1-2
3-4
5-6
7-8
9-10
How often do you currently train per week? Be as specific as possible.
1-2 times a week
3-4 times a week
5-6 times a week
7+ times a week
I’m not training at the moment
How many hours do you sleep on average?
Less than 6 hours
6-7 hours
7-8 hours
More than 8 hours
What is your maximum spending limit per week for groceries?
€0 – €50
€51 – €100
Does not matter
Do you want to train at home, in the gym or a combination of these?
Home
Gym
Combination
If you want to train at home, please indicate which attributes you have at home
How often do you want to train? And on which days do you want to train?
Besides fitness, do you do other activities outside the home? (e.g. walking, cycling, padel, football or other sports)
Do you suffer from medical complaints/injuries or have you ever had operations that we should take into account?
Do you want to focus on a specific muscle group(s)?
Do we have to take dinner into account? Who are you eating with? Do you cook for yourself? Be as specific as possible.
Are there things you don't like, are allergic to or don't eat for vegetarian reasons?
Are there any foods that you really like?
Do you use nutritional supplements?
Are you taking medication?
Photo front
Max. bestandsgrootte: 64 MB.
Photo side
Max. bestandsgrootte: 64 MB.
Photo back
Max. bestandsgrootte: 64 MB.
How motivated are you? Give a score from 1 to 100. (1 = not at all motivated, 100 = extremely motivated)
0 – 25
25 – 50
50 – 75
75 – 100
100+
Complete the intake form
(Vereist)
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