Pre-Exercise Screening Quiz

Pre-Exercise Screening Quiz

Use this form if you have purchased a program from Off The Track Training or Joy's Fitness Hub.
Tag
Full Name*

First NameLast Name
E-mail*

Confirmation Email
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone*
Mobile Phone*

Family history of heart disease (stroke, heart attack)

FatherBrotherMotherSisterDaughterSon
Do you smoke cigarettes on a daily or weekly basis?*

YesNo
If currently smoking, how many per day or week?

Have you been told that you have high blood pressure?*

YesNo
Have you ever been told you have high cholesterol?*

YesNo
Have you ever been told you have high blood sugar?*

YesNo
Are you currently taking a prescribed medication(s) for any medical condition(s)?*
If yes to the above question, please provide details of your medical condition(s)?
Are you pregnant or have you given birth within the last 12 months?
If yes to the above question please provide details on how many months pregnant or postnatal you are?
Waist measurement (cm)*
Resting heart rate (beats per min)*
Height (cm)
Weight (kg)*
Anything else I should know ?
Thanks for taking the time to submit this form! It's important that we acknowledge our medical conditions so that we are all operating safely and within our capacity.
Signature - Type Full Name*
Should be Empty: