Health Questionnaires

Emergency contact name *

Emergency contact number *

your health (required)

1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke? *

Yes No

2. Do you ever experience any unexplained pains or discomfort in your chest, at rest or during physical activity/exercise? *

Yes No

3. Do you ever feel faint, dizzy or lose balance during physical activity or exercise? *

Yes No

4. Have you ever had an asthma attack requiring immediate medical attention at any time over the last 12 months? *

Yes No

5. If you have diabetes (type I or II) have you had trouble controlling your blood sugar (glucose) in the last 3 months? *

Yes No

6. Do you have any diagnosed muscle, bone or joint pain or soreness that is made worse by particular types of activity? *

Yes No

7. Do you have any other condition(s) that may require special consideration for you to exercise? *

Yes No

If you have answered yes to question 7 please provide more detail: *

If you have answered yes to any of the 7 health questions please confirm you have sought guidance from an appropriate allied health professional or medical practitioner prior to undertaking physical activity/exercise *

Yes I have

I believe that to the best of my knowledge, all of the information I have supplied within this questionnaire is correct *

Yes I do

More health (optional)

Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last six months? *

Yes No

Have you been told you have new high cholesterol? *

Yes No

Have you spent time in hospital (including day admission) for any medical condition/illness/injury during the last 12 months? *

Yes No

Are you currently taking any prescribed medication(s)? *

Yes No

Do you have any family history of heart disease? *

Yes No

If yes - please list relationship to you & their age when diagnosed: *

Have you been told that you have high blood pressure? *

Yes No

Are you pregnant or have you given birth within the last 12 months? *

Yes No

Do you have any muscle, bone or joint pain or soreness that is made worse by particular types of activity? *

Yes No

More about you (optional)

Please describe your current physical activity/exercise levels : *

What are your main exercise goals? *