Initial Questionnaire
This Questionnaire is personal and private. Your data will be used only to fit your Core Training Workout to you in the best possible way. The data stored is only for the use of The Core Trainer so it is of great importance that you give accurate and true answers to all questions.
First name *
Your answer
Last name *
Your answer
Profession
Your answer
Email address *
Your answer
Birth date *
MM
/
DD
/
YYYY
Part 1
Medical History
Heart disease *
If you are taking medication please also select "other" and list the medication you are taking
Required
Hypertension *
If you are taking medication please choose also "other" and list the medication you are taking
Required
Family history on Coronary Artery Disease *
If you are taking medication please also select "other" and list the medication you are taking
Required
Smoking habit *
If you are a smoker please also select "other" and state how many cigarettes per day
Required
Respiratory conditions *
If you are taking medication please also select "other" and list the medication you are taking
Required
Joints conditions *
If you are taking medication please choose also "other" and list the medication you are taking
Required
Diabetes *
If you are taking medication please also select "other" and list the medication you are taking
Required
Cholesterol *
If you stated "Yes" also select "other" and list the medication you are taking and your cholesterol value
Required
Do you experience pain in any part of your body? If so, where and when?
Please give a detailed description on where your pain is located and when you normally feel it
Your answer
Do you have other health condition?
Please give a detailed description on any other condition you have or medication you are taking (including any dietary supplements you may be taking)
Your answer
Part 2
Sports History
What is your main equestrian discipline? *
Required
What cardio do you like, or have access to? *
Required
Where will you train? *
Required
What equipment do you have available (in particular if you are training at home)? *
Required
What days per week do you have 30 to 60 minutes available for training? *
Required
Other informations you think is important to share with your core trainer
Please give a detailed description
Your answer
Part 3
Physical Parametres
Age *
Your answer
Height (cm) *
Your answer
Weight (kg) *
Your answer
Body fat (%)
Your answer
Body measurements
Waist circumference (cm) *
Your answer
Hip circumference (cm) *
Your answer
Thigh (cm)
Your answer
Arm (cm)
Your answer
Blood pressure *
Your answer
Resting Heart Rate *
Your answer
Part 4
Motivation, Expectations and Current State
What goals do you wish to achieve? (up to 3) *
Try to define your goals in a way that we can measure them (e.g. reduce waist circumference by 4 cm)
Your answer
Why do you want to achieve these goals? *
Tell us your motivations
Your answer
Why did you contact "The Core Trainer"? *
Tell us your expectations
Your answer
Part 5
After submitting your questionnaire you will receive an email with a payment request and your specially designed workout program will be in it's way! (except if you already paid for the service)
Subscriptions available
Please select here your subscription
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy