Health Form

You need to complete this form before undertaking any physical activities.

We will store this form securely in accordance with GDPR.

This information will be destroyed when you leave the course or training.

Full Name(*)

Please type your full name.

E-mail(*)

Invalid email address.

Please enter your date of birth(*)

Invalid D.O.B

Address

Invalid Input

Post Code(*)

Invalid Input

Telephone Number

Invalid Phone

Please give us your emergency contact details.

Name(*)

Invalid Input

Address

Invalid Input

Post Code

Invalid Input

Email

Invalid Input

Telephone (*)

Invalid Input

The following covers your current state of health. Your fitness and your health goals.

1. What health goals would you like to achieve in the next 3 months?

Invalid Input

2. Name 3 things you could do in order to improve your health?

Invalid Input

What are your main reasons for starting a fitness programme?

How would you describe your general health and fitness?

Invalid Input

Have you ever done any structured exercise?

Invalid Input

If ‘Yes’ what did you do?

Invalid Input

What are your main reasons for starting a fitness programme?

How would you describe your general health and fitness?

Invalid Input

Have you ever done any structured exercise?

Invalid Input

How should we contact you?

E-mail

Phone

Newsletter

Mail

If ‘Yes’ what did you do?

Invalid Input

What type of exercise do you enjoy the most?

Invalid Input

What type of exercise do you dislike the most?

Invalid Input

Diet and Nutrition

On a scale of 1-10 (with 1 being poor and 10 being excellent) how would you assess the quality of your eating habits?

Invalid Input

Would you like any help or advice in changing the quality of your eating habits?

Invalid Input

Do you follow any particular diet or eating patterns?

Lifestyle

Do you drink alcohol?

Invalid Input

Do you smoke?

Invalid Input

If you answered ‘Yes’, would you like help or advice to change these habits

Invalid Input

Medical History

Have you had a major illness or injury in the last 5 years

Invalid Input

If ‘Yes’ please give details

Invalid Input

Are you receiving treatment for any diagnosed medical condition?

Invalid Input

If ‘Yes’ please give details

Invalid Input

Are you taking any prescription medication?

Invalid Input

If ‘Yes’ please give details

Invalid Input

Please indicate if you ever experience any of the following symptoms. Do you:

Ever have severe dizzy spells or episodes of fainting?

Regularly get lower leg pain during walking that is relieved by rest?

Ever experience palpitations or irregular heartbeats?

Are you currently pregnant or have you given birth in the last 6 months?

Invalid Input

Please indicate on the figures below any aches, pains or problem areas. Example - Back pain, Bad knees, Old neck injury

Invalid Input

Are any of these injuries aggravated by exercise?

Invalid Input

Are you currently receiving treatment for any structural problem?

Invalid Input

Please indicate any other health problems you suffer from which you have not already mentioned.

Invalid Input

I can confirm that I have answered all questions honestly and that the information given is correct.

Full Name(*)

Invalid Input

Date(*)

Invalid Input

Physical Activity Readiness Questionnaire (PAR Q)