health and fitness questionnaire

Name* *

First Name

Last Name

Gender *

Female

Male

Have you or your family had any of the following? *

Heart problems

Chest pain or palpitations

Thyroid issues

Dizziness/fainting

Prolapse/weak pelvic floor

Bone or joint problems that could be aggrivated by physical activity

Arthritis

Stroke

High cholesterol

High blood pressure

Low blood pressure

Diabetes

Osteoporosis

Epilepsy

Asthma

No

Do you smoke? *

Yes

No

Have you ever injured any of the following areas of your body? *

Hands/ Wrist

Head

Neck

Back

Torso

Shoulders

Hips

Knees

Upper legs

Lower legs

Ankles/ Feet

No

Which of the following fitness goals are important to you? *

I want to:

Get fitter

Get stronger

Build muscle

Lose body fat

Which of the following health and lifestyle goals are important to you? *

I want to feel:

More relaxed

Less stressed

Healthier

How important to you is it that you achieve the goals you have chosen? * *

Not very

Somewhat

Very

Extremely

What areas are you willing to work on to achieve these goals? *

Exercise

Nutrition

Stress/Mood

Would you like to follow an easy nutritional plan? * *

Yes

No

Maybe

In your experience, which phrase best describes your motivation levels? *

I am self- motivated

I find exercise easier to stick to if I have a partner

I find exercise easier with regular appointments

I usually experience some problems staying motivated

I need constant motivation

From the following list, who is supportive of you achieving your goals? *

Family

Friends

Work colleagues

I herby confirm that all above information is correct and accurate at the time of activity. I know of no reason why i should not participate in an exercise programme. I have been cleared by my doctor or midwife to participate in physical activity. I agree to advise in wrting if any changes to my health should affect my participation. I take part at my own risk and I waive any leagal recourse for damages to myself, my child or property arising from participatuion. *

I agree and this checked box acts as my electronic signiture

I do not agree