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? YesNo How many units of alcohol do you consume in an average week? 1 Large wine = 3 units 1-55-1010-2020+ Have you ever been told you have a heart problem? YesNo Do you suffer from chest pain when exercising or at rest? YesNo Do you suffer with high blood pressure? YesNo Are you taking any medication? YesNo If you answered yes to medication, please give more info here: Do you suffer bone or joint problems? YesNo If you answered yes to joint problems, please give more info here: Have you been diagnosed with Diabetes? YesNo Have you been diagnosed with Epilepsy? YesNo Have you been diagnosed with Asthma? YesNo Are you pregnant? YesNo Have you recently had a baby? YesNo If you answered yes to recently having a baby, how long ago? Do you ever suffer from dizziness or fainting? YesNo Are there any other health problems or injury issues we should be aware of? YesNo 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 YesNo If my circumstances should change in relation to any of the above questions I will inform my trainer as soon as possible YesNo
