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Services (required) Please ChoosePersonal TrainingJoin The Tribe (Instagram Account Name required!)Online Coaching/Competition PrepOne-to-One CoachingClasses
Have you ever had a heart condition and been told you should only do physical activity recommended by your doctor? YesNo
Do you have Diabetes Mellitus? YesNo
Are you currently or have you ever been prescribed drugs for your blood pressure or heart condition? YesNo
Do you have a bone or joint problem that could be made worse by a change in your physical activity? YesNo
Have either your mother, father or immediate family had a heart attack or died suddenly prior to the age of 55? YesNo
Has your doctor ever said you have raised cholesterol? YesNo
Do you currently smoke cigarettes? YesNo
Do you currently exercise on a regular basis (at least 3 hours a week) and/or work in a job that is physically demanding? YesNo
Are you, or is there any possibility you might be pregnant? YesNo
Do you know any other reason why you should not do physical activity? YesNo
If Yes, please specify:
Have you ever or are you currently suffering from any of the following medical conditions? Please specify as necessary. —Please choose an option—High blood pressureDiabetesLow blood pressureAsthma or respiratory illnessEating disordersUnexplained chest painsSurgeryEpilepsy, fainting or dizzinessStrokeCancerNeck, back, hip, knee painAny other joint injuryNone of the above
Please provide any relevant information here:
Are you currently taking any prescribed medication? YesNo
If yes, please specify below:
Have you ever had any pain or injury in your lower back? YesNo
Have you ever had any pain or injury to your head or neck? YesNo
Do you suffer from neck tension, headaches, jaw ache, facial tension? YesNo
If so how often and what triggers it:
Have you ever suffered injury or pain in your pelvis/hips? YesNo
What caused this and when did it occur?:
Have you ever injured or had pain in your legs or knees? YesNo
Have you ever had an injury in your feet or ankles? YesNo
Have you ever had any shoulder injuries or pain? YesNo
Have you ever suffered any pain or injury in your elbows, wrists, hands or fingers? YesNo
Have you ever had any surgery? YesNo
If so what was it for and when was it?:
Are you currently pregnant, or trying to get pregnant? YesNo
Do you have any children? YesNo
If so when were they born?:
For each child, how long were you in labour? Was it natural/caesarean/emergency delivery etc:
Did you have any problems pre or postnatal? YesNo
If so what happend?:
Are you currently participating in any sport or form of exercise? YesNo
What sports or activities have you participated in, in the past?
Please describe your day to day activities. (this could be at work and/or at home):
On average how many hours a night do you sleep? Include usual bedtimes and wake up times.:
Do you sleep through the night or is your sleep often disturbed? Distrubed SleepSleep Through
Do you currently suffer from stress? YesNo
If yes how does this affect you?:
Have you ever taken medication for stress or seen anyone about it? YesNo
Do you suffer from any of the following? —Please choose an option—ConstipationBloatingIBSAbdominal DiscomfortNone
On average how many times per day do you move your bowels? —Please choose an option—1234+
In your own words describe your eating habits on a typical day:
On average how many glasses of plain water do you drink per day?
On average how much alcohol do you consume in a typical week?
Are you currently taking any nutritional supplements at the moment? YesNo
If so, what?:
Do you or have you ever smoked? YesNo
If yes how many per day?:
Why have you contacted us?:
What are you hoping to achieve?:
How much of your current lifestyle are you willing to change to get your results?:
What time have you realistically got available to exercise per week?:
Outside of the studio/gym where are you able to exercise?:
When are you available for your free fitness assessment?
What days and times would you be able to train with us?
I understand that I will participate in an training program that will be catered for my specific needs. I understand that my participation in these activities may include risk of fatal / non-fatal injury. I hereby confirm that I voluntarily accept to engage in the training/exercise that has been tailored to me.
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