Studio health questionnaire Form

PRE-ACTIVITY READINESS QUESTIONNAIRE

Note, the more accurate information you can provide us with now, the more accurate recommendations we can give you. Please be assured this information remains confidential.
Full Name*

First NameLast Name
Gender*

MaleFemaleOther
Today's Date*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState

Postcode
Date of Birth*
Mobile Phone*
Email*
example@example.com
Occupation*
How did you hear about us?*
Were you referred? By whom?*
What is the main reason you have contacted us?*
EXERCISE HISTORY

Are you currently doing exercising?    YES    NO*

If YES...
What are you currently doing? type of exercise
How long have you been doing this?   months/years
How many times a week?   times a week
Are you achieving results?    YES    NO

If NO...
What exercise/sport have you done in the past?   type of exercise
Did you get results?    YES    NO
Why did you stop?   reason
Please describe your past and/or current Pilates experience and where you were attending?*
Please describe your past/current gym, personal training, sporting etc experience and where you were attending?*
MEDICAL BACKGROUND

Do you have a family history of heart disease, stroke, raised cholesterol, high blood pressure or diabetes?    YES   NO*

Are you male over 35 or female over 45 and NOT used to regular vigorous exercise?   YES   NO*

Are you on prescription medication?   YES   NO*
If yes, please describe

Have you been hospitalised recently?     YES   NO*
If yes, please describe

Are you pregnant?   YES   NO*

Have you given birth in the last six weeks?   YES   NO*

Do you smoke?    YES   NO*

Are there any injuries or restrictions in joints, muscles or nerves that may affect your participation in exercise?    YES   NO*
If yes, please describe

Are there any other conditions which may be reason to modify your exercise program?   YES   NO*
If yes, please describe

Do you have or have you suffered from:*

	Yes	No
Arthritis
Asthma
Anxiety
Cancer
Depression
Diabetes
Dizziness
Eating Disorder
Epilepsy
Fainting
High blood sugars
High Blood pressure > 140/90
Heart disease or related conditions
Osteopenia
Osteoporosis
Raised Cholesterol/Triglycerides
Stroke
Other

If you answered yes to any of the above conditions, have you been cleared to exercise by an allied health professional? YES NO
Please provide any further information
FEMALE SPECIFIC QUESTIONS

Do you menstruate on a regular basis?    YES    NO
If so, how long is a typical 'cycle'?   frequency eg 21-35 days

Do you currently have, or have had issues with your menstrual cycle (eg. irregular cycles, missing cycles (and not pregnant), PMS?   YES    NO

At what age did you begin menses?   years old

Have you ever been diagnosed or told you have PCOS, endometriosis or something similar?    YES    NO

Have you had children?    YES    NO
If so, did you have a vaginal delivery or C-Section?
Who did you seek post-birth treatment and clearance from?   insert
Were there any complications during your pregnancy or birth?   YES   NO

Do you ever leak or pee a little when you cough, pick something up, jump, run or do something similar?   YES   NO

Do you do a 'just in case pee'?   YES   NO

Do you ever experience pain in the lower abdomen, pelvis or lower back?   YES   NO

Do you think you are pre-menopausal or going through menopause?   YES   NO

Have you had or are you currently experiencing any hormonal related signs and symptoms such as hot flushes, weight gain, vaginal dryness, foggy head etc?   YES   NO

Has your mother and/or father been diagnosed with (or had) osteoporosis?   YES   NO

Has one or more siblings been diagnosed with or (had) osteoporosis?   YES   NO

Have you ever had broken bones or had stress fractures?   YES   NO
Have you been on diets before?   YES   NO

Have you had an eating disorder?   YES   NO
DESIRES AND GOALS
What results/goals do you want?*

I need to get fitterI want fat lossI need more energyI want to feel confident about my bodyI need to look my absolute bestI need to build muscleI have a specific sporting goalI need more muscle toneI need to get strongerI need to rehabilitate part of my bodyOther
Why is it important for you to achieve these goals?
When would you like to achieve your goals by?
How long have you been thinking about achieving these goals?
Are there any factors that may prevent you from achieving these goals?
(e.g. work, family, time, money)

On a scale of 1 to 10, how committed are you to achieving your goal/s?

	1	2	3	4	5	6	7	8	9	10

1 is I really don't care, 10 is I will do whatever it takes

On a scale of 1 to 10, how confident are you in your ability to achieve your goal/s?

	1	2	3	4	5	6	7	8	9	10

1 is Not at all, 10 is I've can do it 100%

How much time can you dedicate to your goals?   days a week   for   minutes per session

Which time of day can you exercise?   Mornings    Afternoons   Evenings
What exercise or sport do you like?   type of exercise/sport

Are there any that you dislike?   type of exercise/sport

LIFESTYLE

	YES	NO
Do you ever feel weak, fatigued, or sluggish?
Are you consciously aware of the food you eat?
Do you crave sugary foods?
Do you need several cups of coffee to keep you going throughout the day?
Do you often experience digestive difficulties?
Proper nutrition can increase the body's ability to enhance physical and mental performance by up to 80%. Do you feel that a properly structured nutrition and exercise program would benefit you?
Are you happy with the way you look and your health?

How many meals do you typically eat each day?

How many meals do you eat out each week?

How many hours of quality sleep do you get per night?

On a scale from 1 to 10, how stressed do you feel daily?

	1	2	3	4	5	6	7	8	9	10

1 is None, 10 is I'm just hanging on

WARNING: THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR RIGHTS

Agreement for Participating in Personal/Group Personal Training/or Pilates and
The ‘Trainer’ refers to the Personal Trainer and Pilates Trainer
The ‘Activity’ refers to the participation in personal/group strength, fitness and conditioning training, Pilates, assessments and general advice.

I acknowledge that it is a condition of participating in this activity that I do so at my own risk.

I accept all risks and hereby indemnify and release the trainer, their agents, affiliates, employees, members, sponsors, promoters and any person or body directly and indirectly associated with the Trainer, against all liability (including liability for their negligence and the negligence of others) claims, demands, and proceeding arising out of or connected with my participation in this activity.

This release and indemnity continue forever and binds my heirs, successors, executors, personal representatives and assigns.

I acknowledge that participating in this activity may involve a risk of serious injury or even death from various causes including: over exertion, dehydration, equipment failure and accidents with equipment and surroundings.

I recognize the difficulties associated with the activity and attest I am physically fit to participate safely in the activity and that a qualified medical practitioner has not advised me otherwise.

I understand the demanding physical nature of this activity. I am not aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in this activity. In the event that I become aware of any medical condition, injury or impairment that may be detrimental to my health if I participate in this activity my Trainer will be immediately informed. By continuing to participate in this activity, I accept the risks despite these conditions and am still and will always be under the terms of this agreement.

I certify that I am 18 years or older and have read this document and fully understand it.
OR
As a parent or guardian of the participant (a) I agree to the above for myself and on behalf of the participant and (b) I indemnify and will keep indemnified any person or body directly or indirectly associated with the conduct of the activity on the terms referred to.
Signature (guardian/parent to sign if under 18 years of age)

Clear
Name

First NameLast Name
Date

DayMonthYear
Date
Please verify that you are human*
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PRE-ACTIVITY READINESS QUESTIONNAIRE