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Pre-exercise Questionnaire

Please complete this short questionnaire before your first class with me, or if your health conditions have changed since first completing this form.

It is important that you disclose ALL of you existing medical conditions, so I can determine whether you need to seek further medical advice before start participating in the classes.

Your information is confidential and secure.

    YOUR DETAILS

    EMERGENCY CONTACT

    HEALTH QUESTIONS (required)

    1. Do you have a heart condition?
    YESNO

    If YES, please provide details below including if your heart condition is treated and under control:

    2. Have you ever suffered a stroke?
    YESNO

    If YES, please provide details below including when it happened and your doctor's recommendations about exercising:

    3. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
    YESNO

    If YES, please provide details below:

    4. Do you ever feel faint, dizzy or lose balance during physical activity?
    YESNO

    If YES, please provide details below:

    5. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
    YESNO

    If YES, please provide details below:

    6. Do you have diabetes?
    YES, Type 1 diabetesYES, Type 2 diabetesNO

    If YES, please share below if your blood sugar is under control, or if you have had trouble controlling your glucose levels in the last 3 months.

    7. Do you suffer from high blood pressure over 140/90 or low blood pressure below 100/80?
    YES, high blood pressureYES, low blood pressureNO

    If YES, please share below if your blood pressure is treated and under control:

    8. Do you currently have (or have a history of) any injuries / diagnosed problems related to the following areas?
    Please tick all that apply and provide details, or tick "None" if you don't have any current or past injuries.
    NeckShoulderElbowWristHandUpper backLower backHipsKneeAnklesFeetOtherNONE

    If YES, please provide details below including if you have had physiotherapy and what are your physio and/or doctor recommendations about exercising:

    9. Do you currently have (or have a history of) the following health conditions?
    Please tick all that apply and provide details, or tick "None" if you don't have any major health condition that may require special consideration for you to exercise.
    ArthritisCancerGoutLong CovidOsteoporosisRheumatic ConditionSciaticaScoliosisOtherNONE

    If YES, please provide details below including if the conditions are treated and under control. Also, please share your doctor's recommendations about exercising:

    GOALS (optional)

    10. Are you currently physically active/do you exercise regularly?

    If YES, please provide details below including type of exercise, frequency and intensity:

    11. How would you rate your current fitness level?

    12. What are your top 3 fitness goals for the next 6 months?