Personal Training - Health Questionaire

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Your Title:
Your Full Name:
Age:
Your Sex:
Your Email:
Your Mobile/ Phone Number:
Your Occupation:
Have you been Exercising lately?

- If yes, give details?

In general, how would you describe your current health and fitness level?

Which one of the following personal goals are you wanting to achieve?

When would you like to achieve these by?

How long have you been thinking about these goals?

How important is it for you to achieve these goals?

Do you smoke?

- If yes, how many?

Do you suffer from Diabetes?

Is there a family history of heart disease in parents or children prior to age 55?

Have you undergone any surgery in the last year?

- If yes, give details?

Do you suffer from any respiratory problems such as Asthma, etc ?

Do you suffer from any form of Epilepsy?

Are you taking any Drugs or Medication?

- If yes, give details?

If female, have you been pregnant in the last 6 months?

How do you rate your current Stress Levels?

How do you rate your current Energy Levels?

How do you rate your current Quality of Sleep?

How do you rate your current Body Image?

How do you rate your current Self Esteem?

Has your Doctor ever said that you have a heart condition and that you should only do physical activity recommended by a Doctor?

Do you feel pain in your chest when you do physical activity?

Have you had chest pain when you were not doing physical activity?

Do you lose balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by a change in physical activity?

Is your Doctor currently prescribing drugs for your blood pressure or a heart condition?

Do you know of any other reason why you should not do physical activity ?

- If yes, give details?

Additional Information:

   

      07711 394 164            Dale Irvine (Dip. PT., Dip. IIST., MRNT, REPs, Dip. IHM)