Screening Form

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityCounty

Postcode

Email

example@example.com

Telephone

D.O.B

Id like to find out a little more about you in order to tailor the advice I give you. Please answer as honestly and with as much detail as possible.

Do you have any family history of Cardiovascular disease including but not limited to Heart attack, Stroke, Angina, Hypertension and Diabetes? If so please give details:

Family History

Have you had a major illness or injury in the past 5 years? If so, please give details:

Major Illness

Are you receiving treatment or have to undergo periodic reviews for any diagnosed medical condition including Asthma, Diabetes, Hypertension, and Arthritis? If so, please give details:

Chronic Illness

Have you had COVID-19? If so, please detail when, how long the symptoms lasted and the severity:

COVID

Please detail any joint aches, pains or problem areas. Please state whether treatment is currently being undertaken and if any of these mentioned areas are aggravated by exercise.

Structural Health

Are you on any prescription medication including HRT or Bio identical hormones. If so, please give details:

Prescription medication

Please detail any supplements you take regularly:

Supplements

Do you ever become unusually short of breath with very light exercise?

Do you ever experience pain, pressure or tightness in the chest area?

Do you ever feel dizzy or faint?

Do you ever have an irregular heartbeat or palpitations?

What stage of menopause do you consider yourself to be in.

Please give a brief description of a typical week. Do you work, if so how many hours, is it a manual or sedentary role? Do you have caring responsibilities; children, elderly parents etc.

Typical week

Please give a brief description of what a typical day might look like for you? What time you get up and go to bed. When you might eat your meals. How you fill your days when not at work. What you do for fun.

Typical Day

Do you currently partake in any physical activity? This encompasses walking, gym, swim, fitness classes, sports and if you have have a manual job please mention. Please include the frequency, intensity and how long you participate.

Physical Activity

On a scale of 0-10 (0 being not at all), how do the following symptoms affect you?

Hot flushes.

Night sweats.

Poor quality sleep.

Fatigue.

Brain Fog.

Anxiety/depression/low mood.

Gut Health/Digestive issues.

Joint Pain .

Weight gain during menopause/unable to lose weight.

Please give detail of any other symptoms not already mentioned that affect you.

Goals: How would you like to see yourself a year from now?

Goals

I acknowledge that all the information I have disclosed, to the best of my knowledge is correct. I will inform The Health Improvement Coach immediatley if there is any change to my health status. I understand that participating in physical activity comes with a risk and I accept all responsibility for that risk.

I understand that due care will be taken by The Health Improvement Coach. The Health Improvement Coach will only advise within the realms of her expertise and only give evidence based advice.

All information held by The Health Improvement Coach will be kept in confidence. Your personal details and medical information will not be made available to third parties.

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