Health Assessment Form

Health Assessment Questions

Please take a moment to answer the following questions so I can develop an exercise program appropriate for your personal goals and fitness level.

First Name ^*

Surname ^*

Email ^*

Phone ^*

Height ^*

Weight ^*

Age ^*

1. Are you over 40 and not used to regular exercise? ^*

Yes

No

2. Recent hospitalisation and reason (in past 6 months)? ^*

Yes

No

3. Heart disease or other heart condition ^*

Yes

No

4. Do you have High Blood Pressure ? ^*

Yes

No

5. Raised Cholesterol/Triglycerides? ^*

Yes

No

6. Chest pain or palpitations? ^*

Yes

No

7. Rheumatic fever, dizziness and fainting? ^*

Yes

No

8. Have you had major surgery? e.g. knees, shoulder, back ^*

Yes

No

9. Any knee, back or shoulder issues? ^*

Yes

No

10. Arthritis, Asthmatic, Cramps, muscular pain? ^*

Yes

No

11. Do you smoke and if so how many per day? ^*

Yes

No

12. Are you Pregnant? Do you have any children? ^*

Yes

No

13. Are you peri or post-menopausal? ^*

Yes

No

14. Are there any other pre-existing conditions that may affect your exercise program? ^*

Yes

No

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Download: Health Assessment Form.

Note: Please consult your healthcare professional prior to commencing any exercise program.