Health and Wellbeing Questionnaire

Name

First Name

Last Name

Date of Birth

YYYY

Your Mobile

Emergency Contact & Relationship

Emergency Contact Number

Have you ever had any injury, illness, back or joint condition that you may feel could be aggravated by exercise?

Have you ever had Asthma, Diabetes, Epilepsy, Hernia, Dizziness, Gout, Circulation problems, Arthritis or an Ulcer?

Have you ever had a Heart Condition, Stroke, Palpitations, Murmers or pains in the chest?

Have you ever had either high or low blood pressure, and/or high cholesterol level? If YES please indicate which:

Is there a history of heart disease in your family?

Yes

Are you pregnant or recently given birth?

Are you recuperating from a recent illness/operation or injury?

Yes

If YES please detail:

Have you any medical condition that I should be aware of?

Are you taking any prescribed medicine?

Yes

If you have answered yes to any of the above questions or you are not sure please consult your doctor before partaking in any form of exercise. Please detail below. If no, please answer the remaining questions.

Do you currently participate in regular exercise? If yes, please state?

How would you describe your current physical condition?

Please state any food allergies/intolerances/special dietary requirements?

Fitness Declaration I declare that to the best of my knowledge, the information given is correct and I know of no reason why I should not participate in an exercise programme or class. I understand that I enter into any exercise programme entirely at my own risk.

Yes i Agree