health screening

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Health Screening Questionnaire
This is a short questionnaire which will allow me to assess your current level of health and fitness and
your lifestyle. From the information provided I will be able to get an idea of what you will be doing in
your fitness programme and at what intensities. All information you provide will be kept strictly
confidential.
Name.........................................................................................................
D.O.B.........................................................................................................
Gender........................................................................................................
Address.......................................................................................................
.......................................................................................................
Contact number.............................................................................................
Marital status................................................................................................
Occupation..................................................................................................
Dr's name....................................................................................................
Dr's Address.................................................................................................
..................................................................................................................
Dr's contact number........................................................................................
Date......................................................... .................................................
Health Goals/objectives 1.
2.
3.
Do you participate in any sporting activities? YES NO
If yes, what activities?..................................................................................................................
How many hours a week do you take part in sporting activities?................................................

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Do you want to increase the hours you take part in sport? YES NO
What sporting activities would you like to participate in?..........................................................
Do you smoke? YES NO
If yes, how many cigarettes a day?...............................................................................................
If no, did you used to smoke? YES NO
Are you a regular drinker? YES NO
If yes, how many units a week would you say you consume?.....................................................
On average how many hours of sleep do you get a week?...........................................................…read more

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Are you currently on any medication? YES NO
If yes, please state..................................................................................
If yes, will this effect your participation in sport? YES NO
Initial testing
TEST RESULT
Height
Weight
BMI
Waist to hip ratio
Heart rate
Please tick the box if it applies to you.
I have read, understood, and completed this questionnaire
All questions have been answered truthfully and to the best of my knowledge.
Name........................................ Signature......................................................
Address.......................................................................................................
............................................................................................................
Date completed..............................................................................................
Emergency contact details
Name.......................................................................................................
Address......................................................................................................
.......................................................................................................…read more

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Phone number(s)............................................................................................…read more

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