Pre Exercise Questionnaire

What are your main fitness related goals?
Which of our services are you interested in?

PilatesOutdoor FitnessFitness ClassesPersonal TrainingOnline FitnessWeight loss and NutritionWellbeing Retreats
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number

General Health: (Yes/No)
Has anyone in your family under 60 suffered from a Heart Disease, Stroke, High Cholesterol or Sudden Death?
Are you male over 35 or female over 45 and NOT used to regular vigorous exercise?
Are you on any prescribed medication?
Have you given birth within the last 6 weeks?
Are you pregnant?
Do you suffer from any infectious diseases?
Have you been hospitalised recently?
If you have indicated YES for any of the above please give further details:

Do you, or have you suffered from any of the following: (Yes/No)
High Blood Pressure
Raised Cholesterol / Triglycerides
ME
MS
Hernia
A Miscarriage in the past 6 months
Diabetes
Stomach or Duodenal Ulcer
Any Heart Condition
Gout
Heart Murmur
Epilepsy
Palpitations
Glandular Fever
Dizziness or Fainting
Rheumatic Fever
Liver or Kidney Condition
If you have indicated YES for any of the above please give details of condition, medications and approximate date cleared:
If you have answered Yes to any of the conditions above you please take this form to your GP and ask for clearance to exercise before starting with any exercise programme.

Please read the following exercise advice carefully

When beginning a new exercise work at a low level, concentrating on how to do the exercises correctly. When you are comfortable you can work a little harder each time you train. Be sure to limit yourself to a pace where you can still talk comfortably. Should you suffer any injury, illness or condition in the future, please inform your instructor.
Please tick to confirm:

I have read and understand this statement
Statement

I recognise that my instructor is not able to provide me with medical advice with regard to my medical fitness and that this information is used as a guideline to the limitations of my ability to exercise. I have answered the questions to the best of my ability and understand the advice above. I am aware that any physical activity can be hazardous and that there is a risk involved.
Please tick to confirm:

I have read and understand this statement
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