Your full name:

Your email:

Date:

Telephone:

Date of birth:

Age:

Height (Please state if M/cms or Ft/In etc):

Weight (Please state if Kg/lbs/St etc):

Name of contact in case of emergency:

Emergency contact address:

Emergency contact telephone:

Doctors name:

Doctors address:

Doctors telephone:

Are you currently under a doctor’s care: Yes / No?:
YesNo

If you answered Yes to the above, please explain/ provide further information:

When was the last time you had a physical examination?:

Do you take any medications on a regular basis? Yes / No?:
YesNo

If you answered Yes to the above, please list medications and reasons for taking these:

Have you been recently hospitalised? Yes / No?:
YesNo

If you answered Yes to the above, please explain:

Do you smoke? Yes / No?:
YesNo

Are you pregnant? Yes / No?:
YesNo

Do you drink alcohol more than three times/week? Yes / No?:
YesNo

Is your stress level high? Yes / No?:
YesNo

Are you moderately active on most days of the week? Yes / No?:
YesNo

Do you have:

High blood pressure? Yes / No?:
YesNo

High cholesterol? Yes / No?:
YesNo

Diabetes? Yes / No?:
YesNo

Known heart disease? Yes / No?:
YesNo

Rheumatic heart disease? Yes / No?:
YesNo

A heart murmur? Yes / No?:
YesNo

Chest pain with exertion? Yes / No?:
YesNo

Irregular heart beat or palpitations? Yes / No?:
YesNo

Lightheadedness or do you faint? Yes / No?:
YesNo

Unusual shortness of breath? Yes / No?:
YesNo

Cramping pains in legs or feet? Yes / No?:
YesNo

Emphysema? Yes / No?:
YesNo

Other metabolic disorders (thyroid, kidney, etc.)? Yes / No?:
YesNo

Epilepsy? Yes / No?:
YesNo

Asthma? Yes / No?:
YesNo

Back pain: upper, middle, lower? Yes / No?:
YesNo

Other joint pain? Yes / No?:
YesNo

If you answered Yes to the above, please explain:

Muscle pain or an injury? Yes / No?:
YesNo

If you answered Yes to the above, please explain:

Have your Parents or Siblings who, prior to age 55 had:

A heart attack? Yes / No?:
YesNo

A stroke? Yes / No?:
YesNo

High blood pressure? Yes / No?:
YesNo

To the best of my knowledge, the above information is true.

Your signature (Type Full Name):

Date:

Your Witness (Type witnesses full name):

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