Health & Wellness Questionnaire

1
Name* This field is required.
First Name
Last Name
2
Gender
Female
Male
Non-binary
Other
3
Date of Birth* This field is required.
Date
Day
Month
Year
4
Address* This field is required.
Street Address
Street Address Line 2
City
State
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number* This field is required.
6
Email* This field is required.
example@example.com
7
Occupation
8
Heightfeet/inches
9
Weightlbs
10
Please specify if you have one of the following pre-existing condition* This field is required.
Yes
No
Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
Row 0, Column 0
Row 0, Column 1
Do you ever feel faint , dizzy or lose balance during physical activity/exercise?
Row 1, Column 0
Row 1, Column 1
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? (If so, you will need a current action management plan before commencing Kangatraining)
Row 2, Column 0
Row 2, Column 1
If you have diabetes (type I or II) have you had trouble controlling your blood glucose in the last 3 months?
Row 3, Column 0
Row 3, Column 1
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
Row 4, Column 0
Row 4, Column 1
Do you ever experience unexplained pains or discomforts in your chest at rest or during physical activity/exercise?
Row 5, Column 0
Row 5, Column 1
Are you currently pregnant or post-partum?
Row 6, Column 0
Row 6, Column 1
Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
Do you ever feel faint , dizzy or lose balance during physical activity/exercise?
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? (If so, you will need a current action management plan before commencing Kangatraining)
If you have diabetes (type I or II) have you had trouble controlling your blood glucose in the last 3 months?
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
Do you ever experience unexplained pains or discomforts in your chest at rest or during physical activity/exercise?
Are you currently pregnant or post-partum?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
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11
Are you currently taking any medications? If so please also specify what they are prescribed for.* This field is required.
12
Please select if you have ever experienced any of the following conditions:* This field is required.
Yes
No
You have spent time in hospital or urgent care for any medical condition/illness/injury in the past 12 months
Row 0, Column 0
Row 0, Column 1
Joint/Muscle Pain
Row 1, Column 0
Row 1, Column 1
Carpal Tunnel Syndrome (Wrist/finger/hand forearm - pain/numbness or tingling)
Row 2, Column 0
Row 2, Column 1
Nerve damage
Row 3, Column 0
Row 3, Column 1
Knee Pain (Side, front or back)
Row 4, Column 0
Row 4, Column 1
Upper Back/Neck/Shoulder Pain
Row 5, Column 0
Row 5, Column 1
Coccyx Damage or Pain
Row 6, Column 0
Row 6, Column 1
Scoliosis/ Muscle Imbalance
Row 7, Column 0
Row 7, Column 1
Sacrum or Sacroiliac Joint Pain (pain in the very lower mid back - top of buttocks)
Row 8, Column 0
Row 8, Column 1
Migraines/ Chronic Headaches
Row 9, Column 0
Row 9, Column 1
High or Low Blood Pressure
Row 10, Column 0
Row 10, Column 1
High Cholesterol
Row 11, Column 0
Row 11, Column 1
High or Low Blood Sugar Levels
Row 12, Column 0
Row 12, Column 1
Anaemia or taking iron medication
Row 13, Column 0
Row 13, Column 1
Varicose Veins
Row 14, Column 0
Row 14, Column 1
Separation of your abdominal muscles (diastasis recti)
Row 15, Column 0
Row 15, Column 1
Incontinence (Urinary or Faecal)
Row 16, Column 0
Row 16, Column 1
C-section wound discomfort or slow healing or ongoing numbness
Row 17, Column 0
Row 17, Column 1
Episiotomy Cut, Painful Perineum or Tears
Row 18, Column 0
Row 18, Column 1
Other e.g. weak pelvic floor, etc
Row 19, Column 0
Row 19, Column 1
You have spent time in hospital or urgent care for any medical condition/illness/injury in the past 12 months
Joint/Muscle Pain
Carpal Tunnel Syndrome (Wrist/finger/hand forearm - pain/numbness or tingling)
Nerve damage
Knee Pain (Side, front or back)
Upper Back/Neck/Shoulder Pain
Coccyx Damage or Pain
Scoliosis/ Muscle Imbalance
Sacrum or Sacroiliac Joint Pain (pain in the very lower mid back - top of buttocks)
Migraines/ Chronic Headaches
High or Low Blood Pressure
High Cholesterol
High or Low Blood Sugar Levels
Anaemia or taking iron medication
Varicose Veins
Separation of your abdominal muscles (diastasis recti)
Incontinence (Urinary or Faecal)
C-section wound discomfort or slow healing or ongoing numbness
Episiotomy Cut, Painful Perineum or Tears
Other e.g. weak pelvic floor, etc
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
Yes
Row 7, Column 0
No
Row 7, Column 1
Yes
Row 8, Column 0
No
Row 8, Column 1
Yes
Row 9, Column 0
No
Row 9, Column 1
Yes
Row 10, Column 0
No
Row 10, Column 1
Yes
Row 11, Column 0
No
Row 11, Column 1
Yes
Row 12, Column 0
No
Row 12, Column 1
Yes
Row 13, Column 0
No
Row 13, Column 1
Yes
Row 14, Column 0
No
Row 14, Column 1
Yes
Row 15, Column 0
No
Row 15, Column 1
Yes
Row 16, Column 0
No
Row 16, Column 1
Yes
Row 17, Column 0
No
Row 17, Column 1
Yes
Row 18, Column 0
No
Row 18, Column 1
Yes
Row 19, Column 0
No
Row 19, Column 1
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13
Is there any other information you would like me to be aware of?
14
Are you currently physically active?
YESNO
15
What is your current activity level?
Sedentary (office job)
Light exercise (1-2 days/week)
Moderate exercise (3-5 days/week)
Heavy exercise (5-7 days/week)
Athlete (2x per day)
16
What types of exercise do you enjoy?
Cardio (Walking, Running, Biking, Hiking, etc.)
Resistance Training (free weights, machines, etc.)
Restorative (Yoga, Pilates, Stretching, Meditation, etc.)
Classes (Zumba, Cycling, Dance, Bootcamp, HIIT, etc.)
Strength Training (Crossfit, Powerlifting, Bodylifting, etc.)
Martial Arts/ Karate/ Jiu-Jitsu
Aquatics/ Swimming
Other
17
What are your health and fitness goals?
Improve flexibility/ balance/ mobility
Build stength/ Gain muscle
Tone up/ Lean muscle
Lose Weight
Gain Weight
Improve Endurance/ Cardio Performance
Balanced Nutrition/ Eat Healthier
Other
18
What's your 'why' for starting this journey (your motivation)? Do you have any concerns or hesitations?
Huge
Large
Normal
Small
Ok
Ok
19
I confirm that all information entered is true and accurate.
20
Thank you for taking the time to answer these questions. I'll be in touch soon so we can get started!
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