Physical Exercise Questionaire.

 

Personal Details
Name:
Address:
Post   Code:
Home   Tel: Work   Tel:
Mobile   Tel: Email:
Occupation: Date   of Birth:
Emergency Contact Details
Name:
Home   Tel: Mobile   Tel:
Work   Tel: Email:
Your Doctor’s Details
Name:
Address:
Tel:
Physical Readiness

Y

N

Before you start becoming more physically   active it is important to check that is is safe and healthy for you to do so.   By answering the following questions we will be able to establish if you   should first check in with your doctor.
 Common sense is your best guide when   you answer these questions. Please read carefully and answer each one   honestly:
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by  a doctor?
Do you feel pain in your chest when you do   physical activity?
In the past month have you had chest pain   when you were not doing physical activity?
Do you lose your balance because of   dizziness, or do you ever lose consciousness?
Do you have a bone or joint problem (e.g   back, knee or hip) that could be made worse by a change in your physical   activity?
Is your doctor currently prescribing drugs   for your blood pressure or heart condition?
Do you have diabetes

Do you know of any other reason why you   should not do physical activity?

 

 

 

If   you answered Yes to any of the questions above, then please talk to your   doctor or health professional BEFORE undertaking exercise.

 

 

Your structural health
Do   you or have you ever suffered with any of the following (Y/N):
Osteoarthritis Neck/shoulder   pain/injury
Rheumatoid   arthritis Back   pain/injury
Major   trauma/surgery Hip/pelvis   pain/injury
Bone   fracture Knee   pain/injury
If   you answered Yes to any of the above questions, please give brief details: 

 

Other   structural issues not listed, please give details: 
Are   there any other injuries aggravated by exercise? 
Are   you presently receiving physical therapy?
Please outline any particular concerns you   have about your posture: 

 

 

Your lifestyle
What   is the activity level of your job?
What   position do you spend the majority of your working day in?

 

Childbirth
Have you ever had children?
Are  you pregnant or have you given birth in the last 12 months?  If Yes, please give details on the next   sheet:

 


 

 

 
 Date Baby was born. Type:   (Vaginal/Assisted/C-section)
Do you or have you suffered from any of the following:

  •   Pain in the pelvic area, back or knees
  •   Prolapse
  •   Any form of incontinence
  •   C-section  wound discomfort
  •   High/low  blood pressure
  •   Other  pregnancy/birth related issues or concerns

If   so, please give details:

 

 

 

 

 

 

 

 

 

 

 

 

Declaration
I can confirm that to the best of my   knowledge, the information I have given is correct.  I understand that I need to inform my   fitness professional if my medical or health conditions change and that it is   my responsibility to check with my doctor before following any advice or   information provided by a fitness professional.I understand that there is an element of risk   associated with any physically demanding activity, and as a condition of   participation I accept complete responsibility for my own physical and   emotional wellbeing
Print   Name: Date:
Signed: