Name *

First Name

Last Name

Emergency Contact

First Name

Last Name

Have you ever had or do you have?

Anyone in your family under 60 who has suffered heart disease, stroke, raised cholesterol or sudden death?

Are you male over 35 or female over 45 and NOT used to regular vigorous exercise?

Are you on prescription medication?

Have you given birth in the last six weeks?

Have you been hospitalised recently?

Are you pregnant?

Do you have or have had:

Dizziness or Fainting

Stroke

Glandular Fever

Heart Murmur

High Blood Pressure

Palpitation or Pain in Chest

Any heart condition

Diabetes

Epilepsy

Have you ever had or do you have?

Arthritis

Asthma

Cramps

Are you dieting or fasting?

Do you smoke?

Any pain or major injuries in the following areas:

Neck

Back

Knees

Ankles

Shoulders

Any muscular pain

Are there any other conditions which may be reason to modify your exercise program?

Intensity

Hard

Medium

Light

Date

MM

DD

YYYY