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Health screen

The following questions are required to assess your health status before starting a fitness program. The answers you give are completely confidential and will not be released without your prior permission. Please answer all questions with either a yes or no.

YesNo Has anyone is your family under 60 suffered heart disease, stroke, sudden death, or rasied cholesterol?

YesNo Are you over 40 and NOT used to regular exercise?

YesNo Are you on any prescription medication? If yes, please state:

YesNo Have you been hospitalised recently? If yes, please state why:

YesNo Do you smoke?

YesNo Have you given birth in the last six weeks?

YesNo Are you pregnant? If so, how many weeks?

Health conditions and risk assessment

Have you had or do you currently have any of the following? Check if yes, leave blank if no.

Asthma	Raised cholesterol	Diabetes
Any heart condition	Liver or kidney condition	Diziness or fainting
High blood pressure	If yes, please state your blood pressure:
Palpitations or chest pain	Hernia	Arthritis

Injuries, breaks, sprains etc

Have you ever had or do you have any pain or major injuries in the following areas:

Neck	Back	Shoulder	Knees
Ankles	Cramps or muscular pain		Other area(s)

If you answered yes to any please describe the injury:

Are there any other conditions which may be reason to modify your fitness program?

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