Health Screening
Confidential
This has been designed to ensure that you begin your Personal Training 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?
Diabetes
Epilepsy
Back Problems
Arthritis
High/Low Blood Pressure
Asthma
Stress
Thrombosis
Dizziness
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?
Please Select
Yes
No
If yes, please give more details
Is there a family history for coronary heart disease below the age of 60?
Please Select
Yes
No
If yes, please give more detail
Have you had any operations the last 6 months?
Please Select
Yes
No
If yes please give more detail
Do you currently take any medication?
Please Select
Yes
No
If yes please give more detail
Have you had any recent serious illness?
Please Select
Yes
No
If yes please give more detail
Do you have any injuries, bone or joint problems?
Please Select
yes
no
If yes please give more detail
Do you smoke?
Please Select
Yes
No
If yes please give more detail
Do you exercise regularly?
Please Select
Yes
No
If yes please give more detail
Ladies only- are you, or is there any possibility that you are pregnant?
Please Select
Yes
No
If yes please give more detail
Any other additional information:
Submit
Should be Empty: