Mike Wong Fitness - Health Screening

Health Screening

Confidential
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?

DiabetesEpilepsyBack ProblemsArthritisHigh/Low Blood PressureAsthmaStressThrombosisDizzinessOther
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?
If yes please give more detail
Do you currently take any medication?
If yes please give more detail
Have you had any recent serious illness?
If yes please give more detail
Do you have any injuries, bone or joint problems?
If yes please give more detail
Do you smoke?
If yes please give more detail
Do you exercise regularly?
If yes please give more detail
Ladies only- are you, or is there any possibility that you are pregnant?
If yes please give more detail
Any other additional information:
Should be Empty: