Health Screening

1. Have you had any operations or illnesses in the past 5 years  ?         Yes / No

2. Are you taking any medication ?                                                      Yes / No 

3. Are you pregnant / post natal ?                                                         Yes / No

4. Do you presently have any injuries or any in the past 5 years              Yes / No

5. Do you presently or have you ever suffered any back injury ?               Yes / No

6. Are you under medical supervision presently for any issue ?               Yes / No

7.  Do you have epilepsy ?                                                                   Yes / No

8.  Do you have diabetes ?                                                                   Yes / No

9.  Do you suffer from heart problems, high Blood pressure                     Yes / No

10. Do you suffer from asthma or any other lung or breathing issue          Yes / No

11. Do you know of any reason why you should not participate in            Yes / No

     regular physical exercise ?

I undertake physical activity knowing the potential risks and am aware I can ask questions of my personal trainer at any time. I have answered the questions above honestly and will inform my personal trainer in any change to my health or well being as sson as possible

NAME :

SIGNED :

TRAINER SIGNATURE :