Medical and Exercise History Form
biancamckee.com
Full Name
First Name
Last Name
When is your birthday?
Contact Number
-
Area Code
Phone Number
Email Address
example@example.com
What is your weight? (kg)
What is your height? (cm)
What are your primary fitness objectives?
muscle gain
cardiovascular endurance
weight loss
rehabilitation
sport specific training
learn how to lift weights
post/prenatal training
hypermobility specific training
stress management
Other
what is your activity level - sedentary, lightly active, active or very active?
sedentary
lightly active
active
Athletic
Other
Write in any other details I may need to know about your current exercise or activity levels
*
What types of exercise have you done in the past and what would you like to try?
*
Check the conditions that apply to you or any member of your immediate relatives:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Cholesterole
Epilepsy
Other
Check the symptoms that you' re currently experiencing:
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Pregnancy
Weight gain
Weight loss
Musculoskeletal
Post Natal
Any other surgery in the past 12 months
Other
Are you currently taking any medication?
Yes
No
How are your stress levels currently?
good
terrible
Other
Do you have any joint, muscle or ligament injuries or referrals from a GP/physio/osteo etc that I may need to know about?
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Do you use any kind of tobacco or vape?
Please Select
Yes
No
Describe your dietary and including alcohol intake (do you eat 3 meals a day, eat a lot of discretionary foods, how much alcohol do you drink per week etc?)
What days of the week and times are you available and how frequently are you looking to train with a PT?
What are your favourite hobbies, bands or TV shows/movies or sports that you enjoy to do/watch/listen to?
What is the name and phone number of your emergency contact?
*
Media Consent - Your privacy and comfort always come first. I sometimes capture images or short videos from sessions to share the amazing energy and community we’re building. If you do not wish to be featured please let me know below.
what type of services are you looking to take on with myself:
face to face training from your home
team/corporate PT session
goal setting
nutrition
in the gym face to face training
wellbeing coaching session
nutritional accountability
exercise accountability
online group training
group wellbeing session
movement assessment
weight loss
team/corporate mindfulness session
muscle gain
online PT
mindset session
Team/ group exercise session
Strong wellbeing challenge
Other
How much sleep are you getting on average during the night?
Please Select
2-4
4-6
7-8
8+
Do you (yes/no) consent that you have given all accurate health and fitness information to the best of your knowledge and understand the importance of providing this to a PT to ensure the safe and effective delivery and production of exercise/exercise programming.
*
Submit
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