Before we begin your training sessions, we require that you complete our medical questionnaire. Medical screening is very important as it helps inform the fitness program we will develop for you to help you meet your goals.

 

Your Name (required)

Your Email (required)

Your Contact Number (required)

Date of Birth (required)

Body Fat % (required)

Weight (required)

Height (required)

Other Measurements (Optional)

Waist

Arm

Leg (Quad)

During the day how much time do you spend:(required)

Sitting %

Standing %

Walking %

Lifting %

For safety reasons please complete the following: (required)

Has doctor of physician advised you not to take part in any physical activity?
YesNo

Do you have a heart condition?
YesNo

Do you have a history of high blood pressure?
YesNo

Are you taking any medication for high blood pressure?
YesNo

Are you taking any sort of medication?
YesNo

If yes, please state

Have you ever experienced any chest pains whilst doing physical activity?
YesNo

Do you have any known injuries that may affect your exercise programme?
YesNo

If yes, please state

Is there a history of heart attacks in your family?
YesNo

Do you currently smoke cigarettes?
YesNo

If yes, please state quantity

Do you currently drink alcohol?
YesNo

If yes, please state quantity

Do you have any pending surgeries?
YesNo

If yes, please state

Are there any medical conditions you wish to state?
YesNo

If yes, please state

Do you or have you suffered from any of the following:
Heart diseasePainful joint movementBack painDiabetesEpilepsy / SeizureRecent SurgeryFainting / Dizzy spells or black outsInjuries of any kind

This next section is to be completed by women only

Have recently been pregnant?
YesNo

If so, how long ago did you give birth?

Print Name

Date

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