Fit for a Fiver Pre-Exercise Questionnaire

Name * First Last

Email *

Mobile Number *

CURRENT LEVEL OF FITNESS

On a scale going from Absolute Beginner to Athlete, could you please highlight your current level of fitness? *

How many days a week do you currently exercise? *

None 1-2 2-3 >3

What does your current exercise consist of?

Medical History

Please answer the following:

Are you currently a smoker? *

Yes No

Are you pregnant or have you given birth in the last 3 months? *

Yes No

Are you suffering or have suffered from any disease? *

Yes No

If yes, please enumerate them.

Have you ever had a bone, joint or muscle pain or problem that has been aggravated or might be worsen by exercise? *

Yes No

If yes, please provide further information

Do you or anyone in your family have a history of either high or low blood pressure? *

Yes No

Have you had surgery or been in hospital within the last 2 years? *

Yes No

If yes, please provide further information

Do you often feel faint or have spells of severe dizziness? *

Yes No

If yes, please provide further information

Are you currently taking any medication for any reason? *

Yes No

If yes, please provide further information

Is there any other condition that may limit your physical activity, please provide further information: *

HEALTH AND FITNESS GOALS

What is your main health and fitness goal?

Why is this important to you?

DISCLAIMER

She FITNESS and/or Fit for a Fiver shall not be liable or responsible to the participants for any direct, indirect or consequential injury, illness, loss or damage to the person or property of the participant, whatsoever and however arising. The participant accepts that the program developed by She FITNESS and/or Fit for a Fiver has been developed in good faith relying (among other things) on the information provided by the participant. I am aware it is my responsibility to consult with my personal physician regarding my medical fitness to engage in exercise.

All information provided in this contract is true and correct and I have read, understood and accept the above disclaimer and terms and conditions. *

Yes No

She Fitness

CURRENT LEVEL OF FITNESS

Medical History

HEALTH AND FITNESS GOALS

DISCLAIMER