Health & Fitness Screening Questionnaire

Note: Fields with ( * ) are to be filled compulsory.

• 00:00:00
• Client Name: *
• Height (cm): *
• Weight (kg): *
• Exercise: *Rarely1-2/week3-4/week5+/weekExercise: *
• Age: *
• DOB: *
• Fitness Level: *BeginnerIntermediateAdvancedFitness Level: *
• Main Goal: *
• 1. Has a doctor/health professional advised you to avoid or modify exercise? *

  YES

  NO
• 2. Do you have a medical condition that may affect exercise? *

  YES

  NO
• 3. Have you had chest pain, unusual breathlessness, fainting or dizziness during activity? *

  YES

  NO
• 4. Do you have a heart/cardiovascular condition or blood- pressure problem? *

  YES

  NO
• 5. Do you have diabetes or another blood-sugar condition? *

  YES

  NO
• 6. Do you have any bone, joint, muscle, mobility problem, injury or current pain? *

  YES

  NO
• 7. Have you had surgery or a significant injury in the past 12 months? *

  YES

  NO
• 8. Are you taking medication that may affect exercise or physical performance? *

  YES

  NO
• 9. Is there any other health information your Trainer should know? *

  YES

  NO
• IF YES, PLEASE GIVE DETAILS *
• Current injury / pain / limitation: *
• Exercises you cannot or prefer not to do: *
• Other concerns / goals for Trainer: *
• Parent / Legal Guardian Name (For clients under 18): *
• Parent / Legal Guardian Contact (For clients under 18): *
• Sign Here *
  Sign Here
• Please verify you are a human *
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