Health Screening
This has been designed to ensure that you begin your coaching journey quickly and safely. Please complete as honestly and accurately as possible.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Occupation
*
Have you ever, or are you currently suffering from any of the following?
Diabetes
Epilepsy
Back Problems
Arthritis
High Blood Pressure
Low Blood Pressure
Asthma
Stress
Thrombosis
Dizziness
Something Else (Please Specify Later)
If YES, to any of the above please provide more details.
Do you have any heart problems?
*
Yes
No
Is there a family history of coronary heart disease under age 60?
*
Yes
No
Have you had any operations in the last 6 months?
*
Yes
No
Are you currently on any medication?
*
Yes
No
Have you experienced any recent serious illnesses?
*
Yes
No
Do you have any injuries or bone/joint problems?
*
Yes
No
Do you smoke or vape?
*
Yes
No
Do you engage in regular exercise?
*
Yes
No
Ladies only - Are you, or is there a possibility that you are pregnant?
Yes
No
If you answered YES to any of these, please provide more information here.
Any other relevant information you would like to share that may be useful for me to know?
Submit Questionnaire
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