Health Questionnaire 12345 About YouYour trainerShane Cook – Berkeley Square, Clifton & North View, Westbury ParkOllie Reeve – Berkeley Square, CliftonWill Bedford – Berkeley Square, Clifton & North View, Westbury ParkChris Lewis – Berkeley Square, CliftonSteve Uren – Berkeley Square, CliftonLizzie Wessely – Berkeley Square, CliftonDamion Rice – North View, Westbury ParkDevilliers Van den Brink – North View, Westbury ParkLeanne Yardley – North View, Westbury ParkJackie Yonker – North View, Westbury ParkRachel Williams – North View, Westbury ParkJules Taylor – North View, Westbury ParkLiz James – North View, Westbury ParkAlex Prince – North View, Westbury ParkLee Weston – North View, Westbury ParkCharlie McCall – North View, Westbury ParkName* First Last Date of birth* DD slash MM slash YYYY Occupation Contact DetailsMobile* Email* AddressNext of KinHome phone Work phone Your DoctorHome phone Work phone LifestyleThe following questions relate to your health & fitness. The information you provide will be used to evaluate your readiness to begin Personal Training and also to develop a comprehensive programme, designed to achieve your goals. Please take time to answer all questions and ensure that the information provided is as honest, accurate and complete as possible. Thank you.Do you smoke?* Yes No How much do you typically smoke a week? Do you drink alcohol?* Yes No How many units of alcohol do you typically drink a week? How many hours per week do you work?* Up to 20 21-39 40-49 50-59 60+ Have you taken regular exercise in the last 6 months?* Yes No Do you participate in any sporting activities?* Yes No Please provide details… MedicalHave you ever been told by a GP that you have a medical or health condition?* Yes No Do you ever get chest pains when exercising or doing daily chores?* Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity?* Yes No Is your doctor currently prescribing drugs for blood pressure or heart related problems?* Yes No Is your doctor prescribing or are you currently taking any other type of medication?* Yes No Has any member of your family died of heart problems before the age of 55?* Yes No Have you had any operations in the last 5 years?* Yes No Have you ever suffered, or still suffering from any of the following? Arthritis – High Blood Pressure – Epilepsy – Back Problems – Diabetes Thrombosis – Asthma – Excessive Stress – Osteoporosis – Angina – Other* Yes No Do you have any injuries at present?* Yes No Are you pregnant or have you given birth in the last 6 months?* Yes No Please provide details…Your GPHas your GP ever told you that you are overweight Yes No Has your GP ever told you that you have high blood pressure? Yes No Has your GP ever told you that you have high cholesterol? Yes No How strong is your commitment to achieving your goals?* 1 2 3 4 5 6 7 8 9 10 On a scale of 1 to 10, 1 being not very committed and 10 being very committedHow many exercise sessions can you realistically commit to each week with your trainer?Please indicate the most applicable feeling to you I detest exercise I do not mind exercise I enjoy exercise On a scale of 1 to 10 how would you assess your level of fitness?* 1 2 3 4 5 6 7 8 9 10 1 being very unfit and 10 being very fitOn a scale of 1 to 10 how would you assess the quality of your diet?* 1 2 3 4 5 6 7 8 9 10 1 being very poor and 10 being very goodDo you follow any particular type of diet? No Yes Please give any details of your dietPlease list your Long-Term goals in order of importancePlease list your Short-Term goals in order of importance Informed consentThank you for taking time to complete this questionnaire. Please read and check the box below to show you have read the Informed Consent, then send your completed questionnaire. My participation in any fitness training programme with Active 8 Health & Fitness Ltd is voluntary. The information I have given is correct to the best of my knowledge.Explanation of the Personal Training sessionsThe sessions will consist of activities that are designed to gradually improve the efficiency with which the body functions, although no guarantee can be made. Exercise levels will be progressive and be regulated by the trainer. During the sessions, and for a period after, you may experience local muscular soreness and slight fatigue; these minor discomforts should disappear within 48 hourRisk and discomforts of the Personal Training sessionsThe reaction of the body to certain activities cannot always be predicted. There exists the risk that certain changes occurring during or following exercise, these include abnormalities in blood pressure, heart rate or in very rare cases cardiac complications. Should you feel unwell or unsure please let the trainer know immediately. Every effort will be made to avoid any adverse reaction; your trainer is qualified in emergency resuscitation (CPR), is aware of emergency procedures and will minimise the risk of any unlikely events should they occur. A doctor will not be present during the sessions.ConfidentialityAll information acquired during the Personal Training sessions will be treated as confidential.EnquiriesYou are free to stop the session at any time. Please make sure that before signing this form all your questions have been answered. Take as much time as you wish to think it over and if you wish, discuss your participation with you doctor.Consent Yes, I have read the Informed Consent information
