""
1


Health Questionnaire
First name
Surname
Date of Birth
Address
0 /
Postcode
0 /
Tel:
0 /
Please read the questions below carefully and answer each one honestly, ticking the appropriate box or adding information if necessary. Your response will of course be kept in the strictest of confidence.
Question Number
YesNo
1) Has your doctor ever said that you have a heart problem?
2) Have you ever had any chest pain when you were doing any activity?
3) Have you ever experienced any chest pain when you were resting?
4) Are you currently taking medication for a heart condition?
5) Are you currently taking medication for any other problems?
6) Do you suffer from bone or joint problems?
7) Have you had any major illness or major surgery?
8) Have you ever been diagnosed with diabetes?
9) Have you ever been diagnosed with epilepsy?
10) Have you ever been diagnosed with asthma?
11) Have you ever been diagnosed with any other health problems?
12) Are you pregnant?
13) Have you recently had a baby?
14) Do you ever lose your balance because of dizziness or lose consciousness?
15) Are you feeling unwell at present due to cold, flu or headache etc?
If you have answered YES to any of the questions above, please enter the question number and a brief description of the medication and condition below.
Question Number & Further DetailsMedication/Condition/Details
0 /
In the interests of your own health & wellbeing we may request that you consult with your doctor to help us establish your starting point of exercise. All personal information provided will be treated in the strictest of confidence.
IF YOUR HEALTH CHANGES SO THAT YOU MAY THEN ANSWER ‘YES’ TO ANY OF THESE QUESTIONS, YOU MUST INFORM A MEMBER OF STAFF AS SOON AS POSSIBLE.
Do you currently exercise?pick one!
During this exercise can you hold a conversationpick one!
What is your main goal?
0 /
What else would you like to get out of your PT?
0 /
When do you want to start your PT?
Declaration:
Date
Previous
Next