Full Name*
Phone*
Date of Birth*
Occupation
Email*
1. Has your doctor ever said that you have heart trouble? YesNo
2. Have you ever had pains in your chest or got short of breath? YesNo
3. Do you ever feel faint or have spells of dizziness? YesNo
4. Has your doctor said that your blood pressure is too high? YesNo
5. Do you have any joint problems? YesNo
6. Have you been in hospital in the last 3 years? YesNo
7. Are you currently taking any medication? (If yes state medication in notes below) YesNo
8. Are you Pre/Post Natal? YesNo
9. Do you suffer from asthma or breathing difficulties? YesNo
10. Do you suffer from diabetes or epilepsy? YesNo
11. Do you suffer from an allergy? (If yes state medication) YesNo
12. Do you have any infections or infectious diseases? YesNo
13. Do you suffer from any type of chronic illness? YesNo
14. Is there a family history of any major health problems (e.g. heart disease) YesNo
15. Have you been sick/taken days off work in the last 3 weeks? YesNo
16. Are you currently taking any supplements/vitamins? YesNo
17. Do you consider yourself in good physical condition to follow a health & fitness program? YesNo
18. Is there a good physical reason why you should not follow a health & fitness program? YesNo
Notes (if you have answered Yes to any of the questions above, please provide more information)
