Health Questionnaire — Ultra Fitness and Strength

PRE EXERCISE HEALTH SCREENING FORM.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone

Date of Birth

Occupation

GP Name, Surgery and Phone Number

If you suffer, or have ever suffered from any of the following please tick:

Heart disease

Family history of heart attach / stroke

Chest complications eg. asthma

High or low blood pressure

Fainting or dizziness

Diabetes

Epilepsy

Arthritis/joint problems

If you ticked any of the above, please provide details below:

Have you had any surgical operations? If so, please specify and date:

Are you pregnant or recently gave birth?

Do you smoke? If so how many a day?

Do you exercise? If so what type? How often?

Has your doctor ever advised you against exercise due to injury/illness? If so please specify:

Do you have recent back pain or injury? If so please specify:

Are you currently attending physiotherapist / chiropractor / osteopath?

Any other medical problems or relevant information not mentioned above? If yes, please describe:

Please tick the box and click submit in agreement to the Fitness Declaration.

+ FITNESS DECLARATION

I understand that whilst care will be taken to give safe instruction, I accept full responsibility and consider myself fit to exercise. I have answered all questions correctly and all medical and health considerations are noted above. I will inform Ultra Fitness and Strength if any of the above information changes.