Fitness Questionnaire

Fitness Questionnaire

Regular physical activity has many health benefits however, some people should check with their doctor before they start. When planning to undertake physical activity, you should start by answering the questions below. If you are in any doubt, consult with your G.P. before commencing exercise. Please read the questions carefully and answer them honestly with YES or NO. If you answer Yes to any of them please provide more detail in the boxes.
Section 1: General Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
What is your occupation?
What age are you?

16-2021-3031-4041-5051-6061-70Over 70
How often do you currently exercise?

Non exerciser currently1-2 times a week3-4 times a week5-6 times a weekEvery day
What type of sports/exercise do you currently do?
Approximately how many hours movement do you currently do? (e.g., housework, walking to work or school, home repairs, moving around at work, gardening, walking the dog etc)

Fewer than 5 hours5-9 hours10-14 hours15-19 hours20+ hours per week
What other types of movement and/or activities do you do? (e.g., housework, walking to work or school, home repairs, moving around at work, gardening, walking the dog etc)
When it comes to fitness what are your goals - Please Pick your top 3

Lose weightGet fitGet StrongerGet healthierRun around after the kidsSomething I think I should doI am going through Peri/menopauseI want to get my pre-pregnancy body backOther
If Other, please add here
What Type of exercise have you done in the past and liked - Pick all that are relevant

Strength TrainingMetcon workoutsHIIT workoutsRunningYoga/PilatesAerobicsStep AerobicsTeam SportsBoxingMartial ArtsOther
If Other, Please write them below
What are your fitness goals? Please tell me 3 so we can work towards them.
Section 2: General Health
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

YesNo
If Yes, Please give more detail
Do you feel pain in your chest when you do physical activity?

YesNo
If Yes, Please give more detail
In the past month, have you had chest pain when you were not doing physical activity?

YesNo
If Yes, Please give more detail
Do you lose balance because of dizziness or do you ever lose consciousness?

YesNo
If Yes, Please give more detail
Do you have bone/joint problem that could be made worse by a change in your physical activity level?

YesNo
If Yes, Please explain in more detail
Have you ever had any problems with your back?

YesNo
If Yes, Please explain more what is the Issue
Is your doctor currently prescribing any medication for blood pressure or a heart condition?

YesNo
If Yes, can you explain more
Is there any family history of heart disease, stroke, raised cholesterol or high blood pressure?

YesNo
If Yes, Please explain in more detail
Do you suffer from diabetes/epilepsy/asthma?

YesNo
If Yes, can you explain more
Are you pregnant, or have you given birth in the last twelve weeks?

YesNo
If Yes, can you explain type of birth, when you gave birth and how you are feeling now
Do you have, or have you had any illnesses recently?

YesNo
If Yes, Please explain in more detail
Have you recently had surgery?

YesNo
If Yes, Please explain in more detail
Do you know of any other reason why you should not do physical activity?

YesNo
If Yes, Please give more detail
CLIENT DECLARATION

I have read and fully understood the Fitness Questionnaire. I confirm that, to the best of my knowledge, the answers are correct and accurate. I know of no reason why I should not participate in any exercise workout (except those mentioned above). Any equipment I use that is owned by DB Fitness & Nutrition I understand that I would be using entirely at my own risk and waive any legal recourse for damages to myself or property arising from my participation.

I have understood and answered all of the above questions honestly. I understand that I should not exercise if I feel unwell and that if my health changes, I should inform Deborah Branigan of DB Fitness and Nutrition.
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