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Page 1

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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.…

Page 2

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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…

Page 3

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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…

Page 4

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Phone number(s)............................................................................................


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