Client Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Has your doctor ever said that you have a bone or joint problem, such as arthritis, or any medical condition, surgical operation or injury that has been aggravated by exercise or might be made worse with exercise? *

Yes

No

Do you have high blood pressure? *

Yes

No

Do you have low blood pressure? *

Yes

No

Do you have Diabetes Mellitus or any other metabolic disease? *

Yes

No

Has your doctor ever said you have a raised cholesterol (serum level above 6.2mmol/L)? *

Yes

No

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

Have you ever felt pain in your chest when you do physical exercise or at rest? *

Yes

No

Is your doctor currently prescribing you drugs or medication? *

Yes

No

Have you ever suffered from unusual shortness of breath at rest or with mild exertion? *

Yes

No

Is there any history of coronary heart disease in your family? *

Yes

No

Do you often feel faint, have spells of severe dizziness or have your ever lost consciousness? *

Yes

No

Do you currently drink more than the average amount of alcohol per week (14 units)? *

Yes

No

Do you suffer from regular head aches, dizziness, fainting or fits? *

Yes

No

Do you exercise on a regular basis (at least 3 times a week) and/or work in a job that is physically demanding? *

Yes

No

Are you, or is there any possibility that you might be pregnant? *

Yes

No

Do you know of any other reason why you should not participate in a programme of physical activity? *

Yes

No

Is there any further information you feel the instructor should be aware of? *

Yes

No

Today's Date *

Insert the date of agreement

MM

DD

YYYY