anamnesi

General Anamnesis the fields marked with * are mandatory

Surname and name*

E-mail*

Phone*

Address*

City*

Fiscal Code

Profession

Hours available in the day

Anthropometric data

H (cm)*

Weight (Kg)*

Waist (cm)*

Hips (cm)*

Physical activity

Do you do physical activity?

No
Yes

why
yes, which one / s

How many times / week

If you think about physical activity, what, which image comes to mind immediately?

What sport can you not play?

Did you play sports in the past?

Yes
No

If yes, which one/s

How long ago ?

And for how long?

If you went to the gym, how many times did you attend?

How long ?

What did you do?

With what results

meagermedigood

Do you prefer single or group activities?

single
group

Do you prefer to train in the gym, outdoors or by the pool?

gym
outdoors
pool

Currently, how many times / week could you train?

How long ?

Which time slot do you prefer?

General physiological notes

Sports medical ECG / e visits under stress

yesno

Last how long?

Drugs

yesno

Which ?

Blood pressure

HighNormalLow

Smoke

yes

How many cigarettes

Smoke

no

How long have you stopped?

Sleep

How many hours do you sleep on average?

From what time to what time

You have a restful sleep

yesno

Do you ever rest in the afternoon?

yesno

Feeding

Think about feeding yourself

Very badbadVery wellwell

Diseases

Do you have any pathologies to tell me?

Have you undergone any surgery/injury?

yesno

If so, which ones

Use of drugs

yesno

Se si, quali

Do you have pains to highlight?

Determined with which exams
Determined with which exams
Determined with which exams
Determined with which exams
Determined with which exams

Medical report

Are you currently followed by a specialist or other professional?

yesno

If so, which ones

Goal definition

Target

Do you feel motivated to achieve it?

For nothingShortlyQuiteVery

If you've tried in the past what will make the difference this time?

How much do you think the achievement of the result depends on you?

For nothingShortlyQuiteVery

What do you think will be the biggest obstacle to overcome?

How do you plan to overcome this obstacle/s?

WELL, today is the first day of a new lifestyle. Are you ready?

This message is for:

Elisabetta Mastrobuono
Valerio Rea

Privacy

Consenso al trattamento dei dati personali ai sensi del D. LGS n.196/2003
Ai sensi del D. Lgs. n. 196 del 30 giugno 2003 (“codice in materia di protezione dei dati personali”) che tutela il trattamento dei dati personali, il Trainer di seguito indicato informa il cliente di essere il titolare ed il responsabile del trattamento dei dati personali forniti nel presente modulo e che tale trattamento sarà improntato ai principi di correttezza, liceità, trasparenza e riservatezza. 
Ai sensi dell’art. 13 della normativa indicata, si informano i clienti che i dati personali forniti saranno raccolti e trattati nel rispetto delle vigenti norme di legge e successive integrazioni e modificazioni, per finalità connesse allo svolgimento ed all’attuazione del programma di allenamento concordato con il V-Trainer. Si informano, inoltre, i clienti che l’interessato al trattamento dei dati personali è titolare dei diritti di cui al Titolo II (articoli 7, 8, 9 e 10) tra cui, in particolare, il diritto di richiedere in qualsiasi momento l’aggiornamento, la rettifica e la cancellazione dei dati mediante comunicazione da inviarsi al Trainer indicato nel presente modulo.
Preso atto di quanto sopra, do il consenso al trattamento dei dati personali per le finalità di cui sopra.

I agree