Name
*
First Name
Last Name
Email
*
Phone
Country
(###)
###
####
Age
Date of Birth
MM
DD
YYYY
Gender
*
Female
Male
Rathe not specify
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
*
Yes
No
Do you feel pain in your chest when you take part in physical activity?
*
Yes
No
In the past month, have you had a chest pain when you were not doing physical activity?
*
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you have a diagnosed bone or joint problem (for example: back, knee or hip) that could be made worse by a change in your physical activity?
*
Yes
No
Is your doctor currently prescribing medication for blood pressure or heart condition?
*
Yes
No
Are you pregnant or did you have a baby within the last year?
*
Yes
No
Do you know any other reason why you should not do physical activity- if yes please state below
*
Yes
No
If you have answered yes to one or more questions, please use this space to tell us more.
*
If you have answered yes to one or more questions: please check with your doctor before you become or increase your physical activity.
*
Having answered yes to one or more questions, I have sought medical advice and my doctor has told me that I am able to start or increase my physical activity.
Having answered no to all questions, I assume that it is relatively safe for me to start or increase my physical activity, gradually building up from my current fitness level.
Option Two
I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in exercise and that my participation involves some risk of injury.
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Yes
No
What is your Current Exercise level in terms of Frequency, Intensity, Type and for how long?
*
What was your previous exercise level in the same terms. When was this?
*
Reasons for differences between the previous and current exercise routines
*
If you are pregnant or postpartum, please state by how much.
How much of your day is sedentary? (Hours)
State your exercise and activity Likes
State your exercise and activity Dislikes
Do you have any injuries or niggles, weak areas I should be aware of.
*
Do you smoke?
Do you drink alcohol
Nutritional Status- habits, strengths, weaknesses
*
Hobbies & Occupation
State any hobbies and you occupation below. If you have a desk job, please confirm this here
Family history of heart disease- have any 1st degree relatives suffered from a heart attack, stroke or premature death (male under 55, female under 65)- If yes please state below.
What are your goals for your health and Fitness
*
State what your goals are. Aim for short, medium and long term goals. Think about making them specific and measurable. These will be used to track against.
State your reasons for wanting to start this program of exercise and why you want to achieve the goals above?
*
How many days a week can you commit to working out
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1-2
2-3
3-4
4+
How long can you commit to each session?
*
30 mins
45 mins
60 mins
What equipment do you have available to you
*
Access to a Gym
Light Dumbbells
Mixed/Heavy Dumbbells
Light Kettlebell
Pairs of KBs
Mixed/Heavy KBs
Short Resistance bands
Long Resistance bands
Foam roller
Skipping rope
TRX/Suspension trainer
BOSU
Swiss Ball
Barbell
Medicine Ball
Sliders
Which package duration do you want to try?
*
4 Weeks
3 months
6 Months
What date do you want to start your training program?
*
If there is anything else you would like me to know, please let me know below.
