Client Health & Lifestyle Questionnaire

Name *

Sex *MaleFemale

Date of birth *

Telephone (day) *

E-Mail *

GP Name *

GP Address *

GP Telephone *

Emergency contact and phone number *

AsthmaNoYes

Heart DiseaseNoYes

DiabetesNoYes

EpilepsyNoYes

AllergiesNoYes

PregnancyNoYes

Respiratory ConditionsNoYes

Bone and Joint ProblemsNoYes

InjuriesNoYes

DisabilitiesNoYes

MedicationNoYes

HypertensionNoYes

Inherited Risk FactorsNoYes

Chest PainNoYes

DizzinessNoYes

Have you had surgery in the last 6 months?NoYes

Have you ever been advised by your GP to refrain from exercise?NoYes

Is there any other medication condition that you think I should be aware of?

Do you smoke?NoYes

If yes please indicate approx how many cigarettes you smoke per day

Do you drink Alcohol?NoYes

If yes please indicate approx how many units per week

Do you eat a balanced diet?NoYes

If no what changes, if any, would you like to make?

At present how often do you exercise?No ExerciseExercise 1-2 days per weekExercise 2-4 days per weekExercise 4-5 days per weekExercise 6 or more days per week

Please state your current job

Please provide details of your interests and hobbies

What type of exercise or sport do you take part in at present?

What type of exercise do you prefer?

1.

2.

3.

Please select your preferred time to exerciseDaytime Mon-FriEvening Mon-FriWeekendsOther

If other please specify

Are you aware of any reason that would prevent you from undertaking a programme of exercise?NoYes

If yes please provide details

Any Additional Comments:

I consent to my photo being used for the promotion of Lift Up Fitness on their website and/or social media

0 + 7 = ?Please prove that you are human by solving the equation *