Health Form

Your Health and Wellness Form

Thank you for taking the time to fill out the questionnaire form. This is for me to gain an initial understanding of your lifestyle and habits, and how I can further assist you with your goals.
1. Email*
example@example.com
2. Full Name*
3. What is your date of birth?*

MonthDayYear
Date
4. Phone number (For Whatsapp support)*
5. Instagram handle (optional)
Baseline State of Health
If you are between the ages of 15 and 69, this health form will tell you if you should check with your doctor before you significantly change you physical activity patterns. If you are over 69 years of age and are not used to being very active, please check with your doctor.

Please read each question carefully and answer honestly by indicating YES or NO, and giving additional detail where appropriate.
1. Has your doctor ever said that you have condition limiting you to physical activity recommended by a doctor?*

YesNo
2. Do you suffer from any diagnosed or undiagnosed medical health conditions? (E.g. diabetes, high blood pressure, etc.)*

YesNoIf answered yes, please give as much detail as you feel comfortable with.
3. Do you feel pain in your chest when you do physical activity?*

YesNo
4. In the past month, have you had a chest pain when you were not doing physical activity?*

YesNo
5. Do you lose balance because of dizziness or do you ever lose consciousness?*

YesNo
6. Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity?*

YesNoIf answered yes, please give as much detail as you feel comfortable with.
7. Do you have any injuries (past or present) or weak spots? (E.g. recurring lower back pain, tennis elbow, etc.)?*

YesNoIf answered yes, please give as much detail as you feel comfortable with.
8. Is your doctor currently prescribing medication for your blood pressure or heart condition?*

YesNoIf answered yes, please give as much detail as you feel comfortable with.
9. Do you know of any other reason why you should not take part in physical activity?*

YesNoIf answered yes, please give as much detail as you feel comfortable with.
10. Is there anything else I need to know? (eating disorders, etc.)
11. What is your current height? (cm/ft)
12. What is your current weight? (kg / lb)
13. If you wish to do so, please do a BodiTrax scan and record the weight, fat and muscle percentages here
If you answered YES to questions 1,3,4,5,6,8,9:

You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health. If you answered "yes' to the aforementioned questions but have medical clearance to exercise, Primal Power reserves the right to contact your GP / medical professional for proof.
If you answered NO to questions 1,3,4,5,6,8,9:

It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.
I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.*

Clear
Today's date*

MonthDayYear
Date
🌳 Your Lifestyle - Habits & Wellness
How many steps do you average per day?*
What is your occupation?*
Do you smoke or vape?*

YesNoSocially
Do you drink?*

YesNoSocially
Do you take any regular medication?*
Do you take any supplements?*
🍝 Nutritional Habits
How would your rate your diet on a scale of 1-10? *
(1 is poor, 10 is perfect)
What is your biggest struggle when it comes to nutrition? *
How many meals do you have per day?*
What are some of the foods that you can't live without? Go all out - burgers, pizza, baby back ribs, etc. *
Do you have any food allergies / intolerances / sensitivities or dietary requirements?*
Gut health - tick as many symptoms as apply to you:*

General bloatingBloating after mealsGasAbdominal PainConstipationHeartburn / acid refluxNauseaMorning nauseaDiarrheaSome other fun symptom ⬇️
💪 Your Training and Exercise History
How many times per week do you exercise?*
What does exercise normally look like for you?*
How much do you actually enjoy exercise?
(1 = hate it, 10= love it)
What is your biggest struggle when it comes to exercise?*
Do you have any injuries, niggles, aches or pains?*

NoneYes
Do you have any injuries, niggles, aches or pains?*
Once completed, please use the link below to book in for a free 30-min consultation if you have not done so already:

FREE CONSULTATION
Should be Empty:

Your Health and Wellness Form

Baseline State of Health

🌳 Your Lifestyle - Habits & Wellness

🍝 Nutritional Habits

💪 Your Training and Exercise History

Once completed, please use the link below to book in for a free 30-min consultation if you have not done so already:

FREE CONSULTATION