Rees Fitness Client Questionnaire
Please answer these questions so I get an idea of you, your health/injuries and your goals.
Thank you.
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* Required
Email
*
Your email
About you.
What service are you interested in?
*
You are not committing to this. It is just to give me an idea.
Choose
Face to face coaching
Online/virtual coaching
Your Personal Challenge
Consultation/Custom Programme
Full Name
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Other:
Address
*
Your answer
Phone number
*
Your answer
Emergency contact name
*
Your answer
Emergency contact number
*
Your answer
About your health.
Have you been diagnosed with high blood pressure?
*
Yes
No
Do you get head/chest pains during exercise/physical activity?
*
Yes
No
Please detail any head/chest pains below
Your answer
Do you have a family history of heart conditions?
*
Yes
No
Please detail any family history below
Your answer
Do you suffer from asthma or any chronic respiratory condition?
*
Yes
No
Please detail any asthma or respiratory conditions below
Your answer
Have you been diagnosed with any current illness/condition (diabetes, epilepsy etc)?
*
Yes
No
Please detail any illness/condition below
Your answer
Do you currently suffer from any joint problems/aches (hips, knees, shoulders, elbows, neck, back)?
*
Yes
No
Please detail any joint problems/aches below
Your answer
Do you smoke?
*
Yes
No
Are you on any medication/drugs with side effects?
*
Yes
No
Please detail any medication and side effects below
Your answer
Do you have trouble sleeping or are stressed/anxious?
*
Yes
No
Please detail any sleeping problems or stress/anxiety below
Your answer
Would you class yourself disabled in any way (physical, learning etc)?
*
Choose
None
Physical
Learning
Other
Please detail any disability below
Your answer
Are you currently pregnant or given birth in the last 6 months?
*
Yes
No
Any other health related issues not covered so far, you think I should be aware of?
Your answer
About your training.
In your average week, how often do you currently do deliberate "exercise"?
*
Choose
None
1-2
3-4
5 +
Please detail your current exercise levels below
Your answer
What are your 6 month exercise goals
*
Your answer
What are your 12 month exercise goals
*
Your answer
What exercise equipment do you currently have access to?
*
Full gym, weights, bands etc
Commercial gym
Weight machines
Cardio machines
Barbells
Dumbells
Kettlebells
Resistance bands
Medicine balls
Other:
Required
Where did you hear about Rees Fitness
Your answer
Disclaimer
*
Fitness training may include activities such as running, stretching, lifting weights and using fitness equipment. PLEASE ask questions if you are not clear about anything. PLEASE also notify your coach if you feel you should not do a particular exercise for ANY reason. Any fitness training contains certain risks. This training is designed to minimise these risks. However, if at any time during an exercise session you feel pain or discomfort YOU MUST STOP IMMEDIATELY and inform your coach. I hereby state that I have read, understood and answered all the questions truthfully. I also state that I wish to participate in the range of activities including cardiovascular and resistance (weight bearing) exercise. I realise that these activities involve the risk of injury or even death.
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