Your Name (required)
Your DOB (required)
Your Email (required)
House/Flat Number/Name (required)
What health goals would you like to achieve over the next 3 months?
What 3 things could you do in order to improve your health?
What are your main reasons for starting a fitness programme?
Other? Please give further info:
How would you describe your current general health and fitness?
Very badBadAverage UntrainedAverage TrainedTrainedGoodAthleteElite Athlete
Have you done any structured exercises before?
If yes, what did you do?
What did you enjoy the most?
What did you dislike / least enjoy?
What would you say are the main barriers preventing you from exercising?
Lack of facilities
Lack of Knowledge
If doing gym sessions, please state which gym:
On a scale of 1 -10 (1 = poor, 10 =excellent) assess the quality of your eating habits:
Would you like help and advice to change the quality of your eating habits?
If yes, please give any details you wish at this stage:
Do you smoke?
NoYes If yes, how many cigarettes/cigars/vapes per week Less than 1011-3031-5050+
Do you drink alcohol?
NoYes If yes, how many glasses per week Less than 1011-2021-2930+
If yes, would you like help and advice to change these habits?
You should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor.
Please read each question carefully and answer honestly by indicating YES or NO.
Have you had a major illness or injury in the last 5 years?
YesNo - If yes, please give details:
Are you receiving treatment for any diagnosed medical condition?
Are you taking any prescription medication?
Do you ever get unusually short of breath with very light exertion?
Do you ever have pain, pressure, heaviness or tightness in the chest area?
Do you regularly have unexplained pain in the abdomen, shoulders or arm?
Do you know of any other reason why you should not take part in physical activity?
Please indicate if you have ever experienced any of the following symptoms/
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?
Do you experience aches, pains and problems in any specific areas:
e.g. "I always get knee pain when running"
Please give details of any injury areas:
Are these injuries aggravated by exercise? YesNo
Are you receiving treatment for any structural problems? YesNo
Please indicate any other health problems you suffer from which are not already mentioned:
I confirm that I have answered all questions honestly & the information given is correct.
I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury
Sign (Please type name/initials): (required)
Date Signed: (required)
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