Client Questionnaire
Please read and fill in the form with as much detail as you can - as it will all me to plan the classes more effectively and include any necessary regressions/progressions! Any information provided by you will not be shared with any third parties.
Full name: *
Your answer
Address: *
Your answer
Telephone number: *
Your answer
Email address: *
Your answer
GP name: *
Your answer
GP Address: *
Your answer
Emergency Contact Name: *
Your answer
Emergency Contact Telephone Number: *
Your answer
Do you have any children at home? *
If yes, how old are they? (please note, if you have any children under 18 months, or you suffered any injuries/health issues after your delivery, I will need you to fill out my postnatal client questionnaire! Please get in touch to request this) *
Your answer
Are you: *
On a scale of 1 to 10, how would you rate your sleep? *
Awful
Very good
On a scale of 1 to 10, how would you rate your diet? *
Awful
Very good
Describe as best you can a typical day's food intake, from breakfast through to dinner (and include all drinks!) *
Your answer
Are you taking any vitamins or supplements? *
Please provide details of what vitamins/supplements you are taking:
Your answer
Are you on any medication? *
If yes, please provide details (type NA if not applicable): *
Your answer
Do you ever experience difficulty with your bowel, win or urinary urges? *
Do you ever suffer from constipation? *
Do you ever lose urinary control when laughing, sneezing, jumping, coughing or moving quickly? *
If so, have you ever seen a women's health physio regarding this? *
Are you ever incontinent overnight? *
Do you ever experience a sensation of pressure in your vagina or rectum (like a tampon falling out) or noticed any protrusions from either? Or has anyone ever said you may have a prolapse? *
Have you undergone any major injuries or surgery in the last five years? *
If yes, please provide details, including how your recovery was/is going (type NA if not applicable): *
Your answer
Have you suffered from any major illnesses in the last five years? *
If yes, please provide details, including how your recovery was/is going (type NA if not applicable): *
Your answer
Do you or have you ever smoked? *
On a scale of 1 to 10, how would you rate your fitness? *
Awful
Very good
Please provide details of any sort of exercise you currently do (this doesn't have to be gym-based, it might include walking the dog!) *
Your answer
Have you ever been advised by your doctor that you have a heart condition and should ONLY do physical activity recommended by a doctor? *
Do you ever feel pain in your chest when you do physical activities? *
Have you ever felt chest pain when NOT doing physical activity? *
Do you ever lose consciousness or fall over as a result of dizziness? *
Do you have a bone or joint issue that is aggravated by physical activity? *
If yes, please provide details:
Your answer
Has your doctor ever recommended medication for your blood pressure or heart condition? *
Are you aware, through your own experience or a doctor's advice, of any other physical reason against your exercising without medical supervision? *
How is your health in general, do you need to tell us about any other health issues that you have? *
Your answer
List up to five goals that you have in mind for your training with me (this can be a tricky one, but try and think of at least one!): *
Your answer
I have read, understood and completed this questionnaire to the best of my knowledge: *
Please type your name and today's date below (to serve as an electronic signature): *
Your answer
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