Health Questionnaire
Your information will be kept confidential and stored to be in compliance with GDRP.
*
Your answer
07873873103 *
Your answer
27/12/1993 *
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Gender
need to get back to Pilates to ease back and neck
Your answer
pretty good
Your answer
Even better
Your answer
Long hours At work
Your answer
How would you rate your current fitness level
1 (Low)
2
3
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5
6
7
8
8
10 (High)
:
How would you rate your motivation and readiness to start exercising?
1 (Low)
2
3
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5
6
7
8
9
10 (High)
:
How would you rate your stress levels?
1 (Low)
2
3
4
5
6
7
8
9
10 (High)
:
How would you rate your emotional level?
1 (Low)
2
3
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5
6
7
8
9
10 (High)
:
In Case of Emergency Contact Name:
Your answer
Relationship to you
Your answer
Are you currently under a doctor’s care?
If yes please explain why
Your answer
Occupation and hours worked per week if applicable
Your answer
Lifestyle Information
Do you smoke?
If yes, how many a day?
Your answer
Are you currently active?
If yes how many minutes per week and what type of activity?
Your answer
Medical History
Do you take any medications on a regular basis, if yes please list medications and reasons for taking.
Your answer
Have you been recently hospitalised, if yes please give the date and reason.
Your answer
Have you ever received radiotherapy, if so where and how long ago?
Your answer
Have you had any surgeries, if yes please state why and give dates
Have you had any accidents or injuries, if yes please state why and give dates
Your answer
Are you pregnant?
Do you have or have you had:
Yes
No
High blood pressure
Low blood pressure
High cholesterol
Diabetes
Heart Issues
A stroke
Lightheadedness or fainting
Emphysema
Thyroid or kidney issues
Epilepsy
Asthma
Back pain
Arthritis
Gynecological issues
Is there anything else you think we should know?
Your answer
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