Health QuestionnairePersonal Training YOUR CONTACT INFO Name * Prénom Nom de famille Email address * Mobile * Pays (###) ### #### Address * Adresse 1 Adresse 2 Ville Région/Province Code postal Pays Date of birth * MM JJ AAAA Occupation YOUR PHYSICAL ACTIVITY How frequently do you exercise? * Not at all 1 time per week 2-3 times per week More than 3 times per week For how many years have you exercised? * What sports or types of physical activity do you enjoy? * What are your fitness goals? * YOUR HEALTH 1. Has a doctor warned you that you might have a heart problem and advised you not to practice any sport or physical activity without medical supervision? * NO YES If YES, please describe 2. Have you experienced any chest pain during physical activity? * NO YES If YES, please describe 3. Have you experienced any chest pain in the past month? * NO YES If YES, please describe 4. Have you ever fainted or did you fall because of dizziness? * NO YES If YES, please describe 5. Do you have any problems related to your bones or joints that could worsen as a result of physical activity? * NO YES If YES, please describe 6. Has a doctor ever prescribed you medication for hypertension or a heart condition? * NO YES If YES, please describe 7. Do you have any respiratory problems (e.g., asthma, brochitis, etc.)? * NO YES If YES, please describe 8. Do you have any back problems? * NO YES If YES, please describe 9. Is there any reason that might prevent you from doing sports without medical supervision? * NO YES If YES, please describe 10. Do you have any of these risk factors? * Heart disease Hypertension High cholesterol Diabetes Body Mass Index > 25 Smoking habit None of the above OUR TERMS & CONDITIONS Please indicate that you have read and understand the following terms and conditions. * *** If you answered YES to any of the questions above, we advise you to consult a doctor BEFORE you start or increase your physical activity. *** Please advise the Instructor before each class if for any reason your ability to exercise has changed. Personal Training exercises are very safe but, as with all forms of physical exercise, if you have any doubts about the suitability of the exercises, you should refer to your medical practitioner. The Instructor can accept no liability for personal injury related to participation in a class if a) Your doctor has advised you against such exercise; b) You fail to observe instructions on safety or technique; or c) Such injury is caused by the negligence of another participant in the class. Please let us know if you are unable to attend your class. Classes cancelled less than 24 hours in advance will be charged to you. Please consult the conditions on our price list. I have read and understand the terms. Signature * Type your full name plus the date. Thank you for your responses. We look forward to meeting you in our Studio!
