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Name
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In case of any emergency, who should be contacted and how?
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Are you currently active? If so, what type of exercise do you do and how many days per week do you exercise?
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Which exercises do you enjoy more?
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Which exercises do you enjoy less?
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Which exercises or types of exercises are you keen to learn about or try?
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Has your doctor ever said you have heart trouble? If so, please describe:
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Do you frequently suffer from pains in your chest?
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Yes
No
Do you often feel faint or have dizzy spells?
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Yes
No
Has your doctor said that your blood pressure is too high, or are you currently taking high blood pressure medication?
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Yes
No
Are you diabetic?
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Yes
No
Do you have respiratory problems? If so, please describe. If not comment none or not applicable.
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Are you or could you be pregnant?
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Yes
No
Are you over the age of 65 and not accustomed to exercise?
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Yes
No
Do you currently smoke? If yes, how many? If no, have you ever regularly smoked?
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How would you rate your overall physical health?
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Poor
Fair
Good
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Is there any reason not mentioned here that might limit your activity or be adversely affected by an exercise program? If so, please describe. If not note none or not applicable.
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Please list any medications you are currently taking. If none, note none or not applicable.
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Please tell us about anything else that you feel may be relevant:
Have you or do you plan to consult your doctor before beginning a training programme?
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I understand this is an electronic signature and I have answered the questions to the best of my knowledge and noted everything I feel is relevant.
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