Bdy365 Health Screening

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

First NameLast Name
Phone Number

Country CodePhone Number
Date Of Birth

DayMonthYear
Date
Occupation
Have you ever, or are you currently suffering from any of the following?

DiabetesEpilepsyBack ProblemsArthritisHigh Blood PressureLow Blood PressureAsthmaStressThrombosisDizzinessSomething Else (Please Specify Later)
If YES to any of the above, please provide more details...
Do you have, or have you ever had a heart problem or suffer from chest pains?
Is there a family history for coronary heart disease below the age of 60?
Have you had any operations the last 6 months?
Do you currently take any medication?
Have you had any recent serious illness?
Do you have any injuries, bone or joint problems?
Do you smoke or Vape?
Do you drink alcohol?
If yes how often
Do you take any other recreational drug?
Do you exercise regularly?
Ladies only- are you, or is there any possibility that you are pregnant?
If you answered YES to any of the above please provide more information here...
Any other additional information that may be useful for me to know?
Should be Empty:

HEALTH SCREENING