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Health Questionnaire
Contact
First and Middle Name
Last Name
Preferred Title
Mr
Mrs
Miss
Prefer not to say
Are you Female, Male or Other/prefer not to say
Female
Male
Other/Prefer not to say
Your email*
Contact Number
Why are you interested in Personal Training?
What is your height? Optional
What is your weight? Optional
What days and times would you like to Train?
Please list any health conditions you may have?
Have you or your direct family had any of the following?
Any Cardiac Conditions
Osteoporosis
Asthma
Gout
Stomach Ulcers
Concussion
Low Blood Pressure
High Blood Pressure
Diabites
Hernia
High Cholesterol
Cramps
Chest Pain
Angina
Epilepsy
Glandular Fever
Liver or Kidney Pain
Neck, Back or Join Pain
Dizziness or Fainting
Arthritis
Stroke
Rheumatic Fever
Muscular Pain
Palpitations of chest
If yes to any of the above, please provide details:
Have you ever been told by your doctor to avoid any type of exercise or strenuous physical activity?
Do you have any allergies or medical conditions or any other circumstances that could influence your ability to exercise?
What best describes your weight history for the last 12 months
Stable
Fluctuating
Increasing
Descreasing
Has your doctor or family member raised your weight as a medical issue?
If you smoke how many do you smoke each day??
0 per day
1-5 per day
6+ per day
If you previously smoked, when did you last smoke?
Has anyone in your family under 60 suffered heart disease, stroke, raised cholesterol or sudden death?
Are you a person over 35 and NOT used to regular vigorous exercise?
Yes
No
Do you take any pills, tablets, medicine or medication?
Have you been hospitalised recently?
Are you pregnant or attempting to fall pregnant?
Are you currently dieting or fasting?
Do you have any known illnesses/diseases that we should be aware of?
Have you ever injured any of the following areas of your body?
Soft Tissue
Feet
Ankle
Knee
Hip
Lower Back
Upper Back
Trunk
Elbow
Shoulder
Neck
Head
Plesae provide details on any relevant injury history
Improve Aerobic Fitness: How important is it to you?
High
Low
Reduce Body Fat: How important is it to you?
High
Low
Increase Muscle Tone: How important is it to you?
High
Low
Strength & Conditioning: How important is it to you?
High
Low
Improved Health: How important is it to you?
High
Low
Improved Agility: How important is it to you?
High
Low
Improved Posture: How important is it to you?
High
Low
Body Building: How important is it to you?
High
Low
Stress Management: How important is it to you?
High
Low
Rehabilitation: How important is it to you?
High
Low
General Health & Fitness Maintenance: How important is it to you?
High
Low
Do you currently exercise?
What exercise do you enjoy?
What exercise do you not enjoy?
Is there any conditions that may affect you exercising?
Please provide any additional Health & Fitness information
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Health Questionnaire
Email address
Submit
Connect
Get Fit and Healthy
0432 366 851
Connected
aztecfitness810@gmail.com
