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WELLBEINGFIT

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Health Questionnaire

Ready to exercise?

Full name

Date of Birth

Email

Address

Mobile

Experience any of the following (past or present)? Tick all that apply.

Heart condition/or diease (for yourself or within your family)

Chest pains/shortness of breath

Asthma, chronic bronchitis or other chest ailments

Dizziness or feeling faint

High/low blood pressure or high cholesterol

Back pain or other bone/joint problem

Severe headaches or migraines

Recovering from recent illness/injury/medical procedure

Currently pregnant or given birth in last 6 months

Issues with pelvic floor health

Presently taking medication?

Any other medical condition I should be aware of?

Any injury, aches, pains or problem area's I need to know about?

If you ticked any boxes above please give details. You are advised to see your GP before engaging in any physical activity

I declare that the information I have provided is accurate & complete

Signature (print name)

Today's date

Thanks for submitting!

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