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Personal Training Enrolment Form
Before our first session please complete the following form for my records.
Name
*
Address
*
Email Address
*
Emergency Contact Details (Only Fill Out If Having PT Package)
Doctors Details (Only Fill Out If Having PT Package)
Have You Experienced Any Heart Problems
*
If 'Yes', Specify in what in 'other' box
Yes
No
Do You Have Diabetes?
*
If 'Yes', Specify in what in 'other' box
Yes
No
Have You Ever Had A History Of Cancer?
*
If 'Yes', Specify in what in 'other' box
Yes
No
Do You Suffer From Epilepsy?
*
Yes
No
Do You Ever Experience Pains In Your Chest or Heart During Physical Activity?
*
If 'Yes', Specify in what in 'other' box
Yes
No
Do You Ever Get Dizzy Spells?
*
If 'Yes', Specify in when in 'other' box
Yes
No
Do You Get Out Of Breathe Easily?
*
If 'Yes', Specify in when in 'other' box
Yes
No
Do You Have Joint or Bone Problems That Could Be Aggravated By Exercise?
*
If 'Yes', Specify in what in 'other' box
Yes
No
Has Your Doctor Ever prescribed Medication For Blood Pressure Or Heart Conditions?
*
If 'Yes', Specify in what in 'other' box
Yes
No
Are You Currently Pregnant?
*
Yes
No
Have You Given Birth Within The Last 2 Years?
*
If 'Yes', Specify in when in 'other' box
Yes
No
Have You Been Advised Against Physical Activity By Your Doctor?
*
If 'Yes', Specify why in 'other' box
Yes
No
Have You Had Any Surgery In The Last 10 Years?
*
If 'Yes', Specify what in 'other' box
Yes
No
Do You Have High Blood Pressure
*
If 'Yes', Specify when last tested in 'other' box
Yes
No
Not Sure
Do You Have High Cholesterol?
*
If 'Yes', Specify what and when last tested in 'other' box
Yes
No
Not Sure
Do You Have A History Of Heart Disease In Your Family?
*
Yes
No
Not Sure
Do You Smoke?
*
If Used To, Specify When You Quit In The 'Other' Box
Yes
No
Your Current Weight?
Your Height?
Your Date Of Birth?
Please Specify In The Box Anything Else Not Covered Above You Think I Should Know In Relation To Your Health & Medical History?
On A Scale 1-10 (1 Mega Stressed - 10 Mega chilled) How would rate your levels of stress?
*
What Factors Would You Say Stress You Out The Most On A Regular Basis?
*
On Average How Many Hours Sleep Do You Get A Night?
*
How Would You Rate The Quality Of Your Sleep? (1 - Have trouble getting to sleep & regularly wake up - 5 I'd sleep through a hurricane)
How Would You describe Your Energy Levels Over The Day?
*
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What is your Everyday Health Score?
Take The Quiz
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