Pre-Exercise Health and Fitness Screening Questionnaire

Pre-Exercise Health and Fitness Screening Questionnaire
Name:*

First NameLast Name
Date of Birth:

DayMonthYear
Phone Number:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
Emergency Contact:

NamePhone Number
Medical History

Please indicate YES or NO to any of the below (past or current)

	YES/NO
1. History of Heart problems (eg. Chest pains, stroke)
2. Diabetes Mellitus, Asthma, breathing or lung problems
3. Palpitations
4. Allergies
5. Cancer (other than skin)
6. Seizures, neurological problems or dizziness
7. High Blood pressure
8. Recent surgery
9. High Cholesterol
10. Smoker
11. Other, please state below (including any medication)

Lifestyle
1. How would you describe your level of activity within your job?

Sedentary (eg. office work)Active (eg. lots of moving, manual labor)Very Active (eg. construction)

2. On a general basis, what does your current daily nutrition consist of?


Breakfast
Mid Morning
Lunch
Mid Afternoon
Dinner
Dessert
Other Eg. alcohol, take away

Injuries
Back
Neck
Head
Legs (R,L)
Shoulder (R,L)
Other Injuries:
Exercise Limitations
What exercises (if any) are you unable or struggle to perform?
Other notes relating to training
CLIENT DECLARATION

I HAVE READ, FULLY UNDERSTOOD AND COMPLETED THIS QUESTIONNAIRE. THE ANSWERS I HAVE GIVEN ARE ACCURATE TO THE BEST OF MY KNOWLEDGE.

Return the completed and signed questionnaire.
Signature

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Date

DayMonthYear
Should be Empty: