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Health questionnaire
Please answer all questions honestly
* Required
Personal Details
Health Details
Terms & Conditions
Personal Details
Email address *
Phone Number*
Full name *
Date of birth *
Today’s date *
‘I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction’
‘I also understand that due to the nature of the online training, the trainer will not be present to correct form so I am participating at my own risk’
Signed: (typed full name and Initials) *
Health Details
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
Yes
No
2. Do you feel pain in your chest when you do physical activity? *
Yes
No
3. In the past month have you had chest pain when you were not doing physical activity? *
Yes
No
4. Do you lose your balance because of dizziness or do you ever lose consciousness? *
Yes
No
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Yes
No
6. Is your doctor currently prescribing drugs for your blood pressure or heart conditions? *
Yes
No
7. Do you know of any other reason why you should not do physical activity? *
Yes
No
If you answered YES to one or more questions:
Talk with your doctor BEFORE you start becoming more physically active.
Thank you! Your submission has been received!
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