Health Questionnaire

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