Assessment Information

Please answer and submit these questions AT LEAST
24 hours prior to your Session.

First Name*

Last Name*

Full Name

E-mail*

Mobile*

1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?*

YesNo

2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?*

YesNo

3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?*

YesNo

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*

YesNo

5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months? *

YesNo

6. Do you have any other conditions that may require special consideration for you to exercise?*

YesNo

Calculation

You answered ‘YES’ to at least 1 of the 6 questions above.

Please seek guidance from an appropriate
allied health professional or medical practitioner
prior to undertaking exercise.

7. Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the 3 different intensities.*

	Light	Moderate	Vigorous / High
Frequency - number of sessions per week
Duration - total minutes per week

Your weighted physical activity/exercise per week is

Your weighted physical activity/exercise per week is
{yourWeighted56} minutes per week

8. Age:*

Gender*

MaleFemaleOther

9. Family history of heart disease (e.g. stroke, heart attack)?

10. Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months?*

YesNo

How many per day ?

11. Have you been told that you have high blood pressure?*

YesNo

If known, what is the value systolic/diastolic (mmHg)?

Are you taking any medication for this condition?

YesNo

Please provide details of this medication:

12. Have you been told that you have high cholesterol/ blood lipids?*

YesNo

Are you taking any medication for this condition?

YesNo

Please provide details of this medication:

Johnny.M Boxing Health & Fitness Pre - Exercise Questionnaire