| Contact Details |
| Name |
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| Address |
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| Occupation |
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| Home phone |
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| Work Phone |
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| Mobile Phone |
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| E-mail address |
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| Age (in years) |
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| Date of birth |
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| Sex |
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| Risk Factors |
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| Have you ever had or has your Doctor
ever diagnosed you as having heart trouble or coronary
disease? |
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| If yes please
give details: |
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| Do you have a family history
of heart problems or coronary disease? |
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| If yes please
give details: |
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| Do you have a history of
high blood pressure (above 140/90)? |
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Have you
recently had surgery or experienced bone, muscle, tendon
or ligament problems
(especially in the back or knees)? |
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| If yes please
give details: |
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| Do you have diabetes? |
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| Do you smoke? |
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| Are you overweight? |
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| Is your diet heavy in fatty
foods and red meat? |
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| Do you ever have pains in
your heart or chest? |
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| Do you ever feel faint or
have dizzy spells? |
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| Has your Doctor ever said
that you have high cholesterol? |
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| Health and Fitness
History |
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| Are you presently engaged in
a regular exercise programme? |
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| Activity |
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Duration |
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| Frequency |
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Intensity |
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| If no please give details of
the last period where you exercised or were regularly
active |
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| Do you smoke? |
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If so, how many per day? |
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| If not, have you ever smoked? |
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For how many years? |
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| When did you give up? |
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How many did you used to smoke? |
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| Do you drink alcohol? |
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If so how many units per week? |
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| Do you drink coffee or colas that
contain caffeine? |
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If so, how many cups per day? |
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| Are you now or have you ever been on a
diet? |
If so please give some details |
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| Do you consider yourself: |
Overweight
Underweight |
How many meals do you usually eat each
day? |
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| Do you usually eat breakfast? |
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How many eggs do you eat each week |
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| How many times each week do
you usually eat the following? |
| Beef |
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Desserts |
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| Pork |
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Fried Foods |
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| Fowl |
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Fast Foods |
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| Fish |
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| Do you regularly use any of
the following? |
| Butter |
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Salt |
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| Sugar |
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Whole Milk |
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| Sweetners |
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| How active do you consider yourself? |
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How would you describe your nutrition
habits? |
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| How would you describe the stress in
your life? |
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Please describe your knowledge of
exercise and fitness |
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| Please describe your knowledge of
nutrition |
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| Medical History and
Present Medical Condition |
| Please tick any medical
conditions you now have or have had in the past |
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| Heart attack, coronary bypass or other
cardiac surgery |
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Extra, skipped or rapid heart beats or
palpitations |
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| Diabetes |
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Stroke |
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| Peripheral vascular disease |
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Phlebitis or emboli |
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| Rheumatic fever |
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High blood pressure |
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| Low blood pressure |
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Chest discomfort |
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| Heart murmur |
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Ankle swelling |
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| Trouble sleeping |
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Migraine or recurrent headaches |
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| Swollen, stiff or painful joints |
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Foot problems |
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| Back problems |
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Shoulder problems |
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| Neck problems |
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Broken bones |
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| Light headedness or fainting |
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Asthma |
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| Emphysema |
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Unusual shortness of breath |
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| Cold hands or feet |
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Epilepsy or seizures |
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| Anaemia |
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Bronchitis |
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| Pneumonia |
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A chronic recurrent cough |
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| Increased anxiety or depression |
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Emotional disorders |
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| Fatigue or lack of energy |
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Stomach or intestinal problems |
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| Ulcers |
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Limited range of motion in joints |
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| Hernia |
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Arthritis |
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| Bursitis |
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| If you have ticked any of
these please explain here: |
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| Please list any prescribed
medications you are now taking |
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| Please list any over the
counter medications or dietary supplements you are now
taking |
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| Please list any illness,
hospitalisation or surgery in the last 2 years |
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| Please list any drug
allergies |
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| Please list date of last
physical examination and results |
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| Goal Setting |
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| Please tick any specific goals and dates
for achieving them |
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By when? |
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By when? |
| Improve strength |
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Increase energy |
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| Improve flexibility |
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Stop smoking |
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| Improve cardiovascular fitness |
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Stop drinking |
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| Improve muscle tone & shape |
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Injury prevention |
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| Improve diet & eating habits |
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Rehabiltate injury |
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| Lose weight |
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Gain weight & muscle |
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| Reduce stress |
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Additional goals, please list |
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| Facilities and equipment
available |
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| Swimming pool |
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Multi gym |
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| Exercise bike |
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Free weights |
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| Treadmill |
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Bicycle |
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| Elliptical trainer |
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| Available time |
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| How much time do you have to
train each week? |
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| What are the best days for
you to train? |
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| Which time of day do you
prefer to train? |
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Thank you for completing the questionnaire, please now click
"Submit" to send it to us.
