Mike Wong Fitness - Health Screening

This has been designed to ensure that you begin your fitness journey quickly and safely. Please complete as honestly and accurately as possible.

Name

Tel No

D.O.B

Occupation

Have you ever, or are you currently suffering from any of the following?

If yes to any of the above please give details

Do you have, or have you ever had a heart problem or suffer from chest pains?

If yes, please give more details

Is there a family history for coronary heart disease below the age of 60?

If yes, please give more detail

Have you had any operations the last 6 months?