QUESTIONNAIRE
Please take your time to fill out this questionnaire in as much detail as possible. The
more information you provide the more we design a program suited to you.
Where did you hear about Get Active Online?
PERSONAL DETAILS:
Name:
Email Address:
Address:
Phone:
Age:
Occupation & Working Hours:
Height:
Weight:
Body Fat: (if known)
Please take some before pictures, front, back and side and email them through with
your questionnaire.
Which program would you like to do? Ultimate Fat Loss Program, 12 week Results
program, 6 week results program or the Quickstart Program.
GOALS:
What would you like us to help you with?
YES/NO
Lose Weight
Tone Up
Improve Fitness
Improve muscle definition
Improve Strength
Create a healthy lifestyle
Increase Energy
Look & Feel Fabulous
Please write down your Goals, be as specific as possible:
1.
2.
3.
Why have you chosen now to change your lifestyle?
Do you foresee any obstacles which you will need to overcome to reach your goals?
Will you be entering any body transformation competitions, eg Body Blitz, Body for
Life etc?
What date did you want to start your new program? Please allow 3 working days
(Monday – Friday) after submitting your payment and questionnaire.
NUTRITION –
Please record a days worth of “normal” eating. Include all foods, quantities, times and
any beverages had throughout the day. (Be as honest as possible as it will help when
designing a program suited to your needs). Include any food weaknesses or times
when you are normally really hungry! The more info the better.
How much water do you drink each day?
Do you drink alcohol, if so how often and how much?
Have you dieted much before?
Are you an emotional eater?
Do you have any food allergies or food dislikes?
Would you like a personalised Supplement plan?
EXERCISE –
Do you currently exercise, if so, please describe the type of exercise, how often you
exercise the intensity and duration of each session? If no, when is the last time you
exercised?
Do you have access to any gym equipment, either at home or in a gym? Please write
down everything you have access to? Eg Swiss Ball, Dumbbells, (please advise
dumbbell or plate weights), treadmill with incline, oval, beach etc
Do you have any injuries or illnesses that would prevent you from participating in
regular exercise? Please explain
How much time can you allocate to exercise each week?
MEDICAL BACKGROUND –
Do you have or had any of the following conditions?
CONDITIONS
Heart Condition
High blood pressure/low blood pressure
High Cholesterol
Diabetes
Depression
Arthritis
Any Chronic Conditions
Musculosketal problems?
Back or Neck Pain
YES/NO
If you answered yes to any of the above, please provide details?
Do you take any prescription medication?
Are you pregnant or had a baby in the last 6 weeks?
Do you smoke?
Have you been hospitalised or had any operations?
Do you have any other conditions or problems (eg Knee pain etc), Please explain in
detail below.
We strongly recommend consulting your doctor
before beginning any exercise program.
It is recommended that anyone who has not undertaken regular exercise in the last 6
months or all males over 35 and females over 40 years of age should have a full
medical and get their doctors clearance before embarking on a new exercise routine.
Anyone with a heart condition will need a medical clearance before undertaking a
regular exercise routine.
Please feel free to provide any further information which may assist us in designing
your own personalised program.
Thank you for you honest information,
You’re on your way to a healthier and happier you!
What is expected from you:
-
Detailed information included in your questionnaire.
Current pictures of yourself.
Honest & regular contact! If you have paid for a full support program
you need to make the most of it. We can only help if we hear from you.
Feedback should be sent in on the requested feedback day so you can
ensure a prompt reply.
Commitment and the desire to change!
What you can expect from us:
-
A personalised program that is suited to your lifestyle based on the
details you provide us in your questionnaire.
Constant support! We are here to help but in saying that we can only do
this if we hear from you. Use your program and get the most out your
program by keeping in regular contact.
Honest feedback! We are here to help you reach your goals & will
provide honest feedback.
Prompt feedback. If you send in your feedback on the specified date
you will get a reply within 24 hours. Feedback submitted late may take
longer to get a reply.
Replies to ALL OF YOUR EMAILS. If you have paid for support you will
get replies to all of your questions and no extra charges if you feel you
need more support or accountability.
Like everyone we do like to take a break each week and if sending emails
on Saturday or Sunday, you may not get a reply until Monday. Existing
clients with any urgent requests just need to put this in their email subject
line and we will respond as quickly as we can.
Ultimately our goal is to help you reach your goals, all we ask is that you
are honest with us and truly try and make each week as good as you can.
This isn’t about being perfect but just giving it your best and never giving
up.
CLIENT CONTRACT
By submitting this questionnaire you agree that the information provided to
Get Active Online – Creating Healthy Lifestyles is true and correct to the best
of your knowledge (all information provided will be treated confidentially).
I acknowledge that by submitting this document, I have voluntarily chosen to
participate in a nutrition and training program consisting of both resistance
training and cardiovascular exercise. I am aware that Get Active Online is not
providing medical advice and they are not medical doctors or dieticians. I have
been informed of the need to obtain a physician’s examination and approval
prior to beginning this exercise program. I acknowledge that I do not have a
medical condition, injury or impairment that will be detrimental to my health if I
participate in an exercise and nutrition program. In the event I become aware
of any conditions which will impact on my ability to continue to participate in
this activity I will immediately inform Get Active Online – Creating Healthy
Lifestyles.
In submitting this document, I acknowledge being informed of the possible
strenuous nature of the program and do so voluntarily. I am aware that
whenever undertaking physical exercise, there are risks of injury or illness.
I understand it is beneficial for me to ask questions regarding my program and
never continue exercise if ill or experiencing pain. By submitting this document
I assume all risk for my health and well being and release Get Active Online –
Creating Healthy Lifestyles of all liability now and in the future.
I acknowledge that to achieve beneficial results I will be required to stick to
the Nutrition & Training Program, provide honest feedback, measurements
and photos as required.
I certify that I have read this document and fully understand it.
Payment Details:
Payment is to be made by the client in advance.
Direct Deposit:
Get Active Online
Bank:
Credit Union Australia
BSB:
804050
Account:
30860198

Please put your name in the Payee Reference and notify us of your
payment so we can get started on your program straight away.
Pay Pal:
Pay Pal enables anyone with an email address to send & receive payments
online. It is safe, quick and easy to use. You can access Pay Pal by clicking
the link on the contact us page http://www.getactiveonline.com/contact.html
If a tax invoice is required please notify us when sending back your
questionnaire.
Cancellation Policy:
If a client cancels within 24 hours after making payment and their program
has NOT BEEN ISSUED a full refund will be provided. 
Money Back Guarantee:
If you follow your nutrition & training plan, don’t skip any of your training sessions
& eat according to plan, YOU WILL GET RESULTS. To be eligible for the Money
back guarantee you will need to keep an ACCURATE food and training diary & fill
in your feedback from EVERY week & submit it on your feedback day. If you
haven’t got results in 6 weeks AND HAVE FOLLOWED YOUR PROGRAM
EXACTLY (that means not missing any training sessions and following your
nutrition plan) we will happily give you a full refund!
Putting your program on hold:
Sometimes things come up or you get sick and you need to put your program on
hold. You can do this at any stage at NO COST as long as you give us 1 weeks’
notice and let us know how long you need to put your program on hold*.
*Programs can only be put on hold for up to one month.