Name
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First Name
Last Name
Date of Birth
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MM
DD
YYYY
Gender
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Today's Date
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MM
DD
YYYY
1. Has a doctor ever told you that you have a heart condition or have you ever suffered a stroke?
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2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
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3. Do you experience shortness of breath with mild exertion?
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4. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
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5. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
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6. If you have diabetes (type 1 or type II) have you had trouble controlling your blood glucose in the last 3 months?
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7. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
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8. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
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Any further comments?
1. Do you have a family history of heart disease (eg: stroke, heart attack)
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List relative and age
2. Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months? If yes, how many per day?
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3. Please enter your height in cm and current weight in kg
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4. Have you been told that you have high blood pressure?
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5. Have you been told that you have high cholesterol?
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6. Have you been told that you have high blood sugar?
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7. Have you spent time in hospital (including day admission) for any medical condition/illness/injury during the last 12 months?
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8. If YES, please provide details:
9. Are you taking a prescribed medication(s) for any medical condition(s)
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10. If YES, please provide details
11. Are you pregnant or have you given birth within the last 12 months?
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12. If YES, please provide details:
1. Do you any current muscle, bone or joint pain or injury that is made worse by particular types of activity?
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2. If YES, please provide details:
3. Please select the areas of your body that you have injured or felt pain in the past:
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4. Please provide more details regarding injury or painful areas ticked above:
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1. Select your CURRENT physical activity/exercise levels:
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In terms of 'intensity'
3. Please provide details about level of exercise experience including years of training under guidance from a qualified exercise professional...
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Resistance training, flexibility work, cardio training, yoga, pilates etc
4. Please provide details of all sports / physical activities participated in over your lifetime:
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1. Please select the 3 most applicable GOALS that you would like to achieve
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2. If you selected 'Other' please enter your additional goals
4. How much time do you have available to exercise?
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Days per week? Time per session? Total Hours per day?
5. Where do you plan to exercise?
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6. If 'Other', where?
7. What facilities / equipment do you have access to?
8. Are there any types of activity you particularly like or dislike?
Please provide details
9. Have you experienced any of the following difficulties with an exercise program in the past?
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10. If 'Other' please explain:
11. Do you see any of these as a likely potential threat to dropping out from this exercise program?
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12. If 'YES', which one?
2. Agreement to Waiver
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3. Signed
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First Name
Last Name
