Name
*
First Name
Last Name
Email Address
*
Phone Number
Has your doctor ever said that you have a bone or joint problems, such as arthritis that has been aggravated by exercise or might be made worse with exercise?
*
Please Select One
Yes
No
Do you have high blood pressure?
*
Please Select One
Yes
No
Do you have low blood pressure?
*
Please Select One
Yes
No
Do you have Diabetes Mellitus or any other metabolic disease?
*
Please Select One
Yes
No
Has your doctor ever said you have raised cholesterol?
*
Please Select One
Yes
No
Has your doctor ever said that you have a heart condition arid that you should only do physical activity recommended by a doctor?
*
Please Select One
Yes
No
Have you ever felt pain in your chest when you do physical exercise?
*
Please Select One
Yes
No
Is your doctor currently prescribing you drugs or medication?
*
Please Select One
Yes
No
Have you ever suffered from unusual shortness of breath at rest or with mild exertion?
*
Please Select One
Yes
No
Is there any history of Coronary Heart Disease in your family?
*
Please Select One
Yes
No
Do you often feel faint, have spells of severe dizziness or have lost consciousness?
*
Please Select One
Yes
No
Do you currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women)?
*
Please Select One
Yes
No
Do you currently smoke?
*
Please Select One
Yes
No
Do you NOT currently exercise on a regular basis (at least 3 times a week) and/or work in a job that is physically demanding?
*
Please Select One
Yes
No
Are you, or is there any possibility that you might be pregnant?
*
Please Select One
Yes
No
Do you know of any other reason why you should not participate in a physical activity programme?
*
Please Select One
Yes
No
If you answered YES to any of the questions above please give details:
*
Please Select One
Yes
No
Date of Birth
*
Name
*
First Name
Last Name
Todays Date
Emergency Contact
Name, Relationship, Phone number
