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Your Personal Details
Name
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First
Last
Gender
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Male
Female
Other
Email Address
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Phone
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Date of Birth
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DD slash MM slash YYYY
Address
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City
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Country
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Post Code
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Emergency Contact Details
Name
*
First
Last
Email Address
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Phone
*
Address
*
City
*
Country
*
Post Code
*
Your Health Goals
What health goals would you like to achieve in the next 3 months?
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Name 3 things you could do in order to improve your health?
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What are your main reasons for starting a fitness programme?
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General conditioning
Muscular strength
No time
Weight/fat loss
Aerobic fitness
Appearance
Stress management
Flexibility
Improve self-esteem
Other
How would you describe your general health and fitness?
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Have you ever done any structured exercise?
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Yes
No
If 'Yes' what did you do?
What type of exercise do you enjoy the most?
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What type of exercise do you dislike the most?
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What would you say are the main barriers preventing you from exercising?
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Lack of facilities
No motivation
No time
Injury/illness
Unfit
Appearance
Lack of knowledge
Family
Work
Diet and Nutrition
On a scale of 1-10 (with 1 being poor and 10 being excellent) how would you assess the quality of your eating habits?
1
2
3
4
5
6
7
8
9
10
Would you like any help or advice in changing the quality of your eating habits?
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Yes
No
Do you drink alcohol?
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Yes
No
Do you smoke?
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Yes
No
If you answered 'Yes', would you like help or advice to change these habits?
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Yes
No
Medical History
Have you had a major illness or injury in the last 5 years
*
Yes
No
If 'Yes' please give details
Are you receiving treatment for any diagnosed medical condition?
*
Yes
No
If 'Yes' please give details
Are you taking any prescription medication?
*
Yes
No
If 'Yes' please give details
Please indicate if you ever experience any of the following symptoms. Do you:
Ever get unusually short of breath with very light exertion?
Ever have pain, pressure, heaviness or tightness in the chest area?
Regularly have unexplained pain in the abdomen, shoulders or arm?
Ever have severe dizzy spells or episodes of fainting?
Regularly get lower leg pain during walking that is relieved by rest?
Ever experience palpitations or irregular heartbeats?
Are you currently pregnant or have you given birth in the last 6 months?
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Yes
No
Structural Health
Please describe and give details of any aches, pains or problem areas.
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Are any of these injuries aggravated by exercise?
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Yes
No
Are you currently receiving treatment for any structural problem?
*
Yes
No
Please indicate any other health problems you suffer from which you have not already mentioned.
*
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