Health Questionnaire

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In order to participate in Personal Training and/or class sessions, please fill out the following medical form.

Full Name

Date of Birth

Please answer by ticking the relevant boxes:

Do you feel any pains in the chest while exercising?

Have you felt any chest pains in the last 6 months?

Have you or do you suffer with a heart disorder?

Do you suffer with high blood pressure?

Are you diagnosed as diabetic?

Do you suffer with epilepsy?

Do you suffer with asthma?

Do you suffer with dizziness or loss of balance?

Have you had any serious illness/operation in the last 12 months?

Do you have any bone or joint problems?

Are you pregnant?

Have you given birth in the last 6 months?

Are you taking any prescribed medication?

Do you smoke?

None of the above.

If you have answered yes to any of the above, please provide relevant details here:

Are you aware of any other reason why you should not exercise?

I declare that the info I’ve provided is accurate & complete

Initials

Today's Date

Thanks for submitting!