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14 Day Online Bootcamp
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Name
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Surname
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Your answer
Email Address
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Confirm Email Address
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Your goal with this 14 Day Online Bootcamp
Your answer
Tick all that apply to you:
Improve Health & Fitness
Lose weight
De-Stress
Improve Sleep
Build better habits
Increase Motivation
How would you describe your sleep?
less than 7 hours
7- 8 hours
more than 8 hours
always inconsistent
Other:
Clear selection
Are you generally stressed?
Yes
No
Maybe
Clear selection
On a scale of 1 to 10 how stressed? 1 being No stress at all and 10 being always on edge with plenty of sleepless nights
1
2
3
4
5
6
7
8
9
10
Clear selection
Do you have a regular menstruation cycle?
yes
No
Irregular Periods
Menopausal
Other:
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Age
Your answer
Height in cm
Your answer
Weight in kg
Your answer
Level of activity throughout the Week
Sedentary (office job)
Light exercise (1-2 days/week )
Moderate exercise (3-5 days/week)
Hard exercise (6-7 days/ week)
Athlete (2x/day)
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What do you want to achieve out of this?
*
Decrease Fat Mass
Increase Muscle Mass
Maintain bodyweight
Not interested in any I am here to Learn about Health & Better myself!
Other:
Any medical issues or history of health problems?
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Your answer
Are you on any medication? If so, what?
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Your answer
Do you have a any allergies?
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How about Food Intolerances?
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How often are you sick per year?
rarely sick
1-2 times per year
more than 3 times per year
Clear selection
Have you ever dieted in the past?
Yes
No
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If yes, where you successful?
Your answer
If Not, briefly explain why this was not a success
Your answer
Are you currently on any specific diet?
Your answer
Do you have any dietary restrictions? If so what?
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Your answer
Have you recently suffered any injuries, If so please explain
Your answer
How much water do you drink daily?
Less than 1 litre
1-2 litres per day
3+ Litres per day
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