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?
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?
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.
Please indicate if you have ever experienced any of the following symptoms/
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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