New Client Questionnare

First name

Last name

Email

Phone

Date of Birth

Day

Month

Year

Emergency Contact Name

Emergency Contact Number

Health & Fitness Goals

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

Exercise History & Preferences

How would you describe your general health & fitness?

Have you ever done any structured exercise?

Yes

No

If YES what did you do?

What type of exercise do you enjoy the most?

What type of exercise do you dislike the most?

Physical Activity Readiness

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

Yes

No

If YES please give details

Are you receiving treatment for any diagnosed medical condition?

Yes

No

If YES please give details

Are you taking any prescription medication?

Yes

No

If YES please give details

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

Ever get unusually short of breath with very light exertion?

Ever have pain, pressure, heaviness or tightness in the chest area?

Regularly have unexplained pain in the abdomen, shoulders or arm?

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 given birth in the last 6 months?

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

I understand that my data will be used solely for the purposes stated and handled in compliance with the General Data Protection Regulation (GDPR)

Print name

Signature

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