health and fitness questionnaire
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Name:
Address:
Mobile:
Occupation:
Age:
Male /Female:
Medical history
1. Have you ever suffered from heart trouble?    
2. Are you presently taking any form of medication?    
3. Do you suffer from chest pains?      
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4. Do you ever have spells of dizziness or feel faint?  
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5.Have you ever had either high or low blood pressure, and/or high cholesterol level?    
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6.Have you ever had asthma, chronic bronchitis or any other chest ailments?    
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7.Do you suffer from severe back pains or any orthopaedic problem?      
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8.Do you suffer from severe headaches or migraines?  
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9.Are you recuperating from a recent illness/operation or injury?
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10. Have you any medical condition that we should be aware of?    
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11. Are you pregnant? If yes how many months?
Is there any history of heart disease in your immediate family (under the age of 55)?      
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PLEASE NOTE:  
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