Your Name (required) Your Date of Birth (required) Your Email (required) Your Mobile Number (required) Home Number Emergency Name & Number Doctors Name & Number Height Weight Do you smoke? Yes No How many units of alcohol do you consume in an average week? 1 Large wine = 3 units 1-5 5-10 10-20 20+ Have you ever been told you have a heart problem? Yes No Do you suffer from chest pain when exercising or at rest? Yes No Do you suffer with high blood pressure? Yes No Are you taking any medication? Yes No If you answered yes to medication, please give more info here: Do you suffer bone or joint problems? Yes No If you answered yes to joint problems, please give more info here: Have you been diagnosed with Diabetes? Yes No Have you been diagnosed with Epilepsy? Yes No Have you been diagnosed with Asthma? Yes No Are you pregnant? Yes No Have you recently had a baby? Yes No If you answered yes to recently having a baby, how long ago? Do you ever suffer from dizziness or fainting? Yes No Are there any other health problems or injury issues we should be aware of? Yes No If you answered yes to health problems, please give more details here? To the best of my knowledge I have answered the questions above correctly at the time of sending Yes No If my circumstances should change in relation to any of the above questions I will inform my trainer as soon as possible Yes No
