Beyond Fitness

Name:
Surname:

Address Line 1:

Address Line 2:
Suburb:
Postal code:

Home number:

Cell:

Email address:

Date of birth:
ID number:
Person to contact in case of emergency:
Name & surname:

Relationship:

Contact number:
 



Medical History
Has your doctor ever indicated that you have heart trouble?
(yes or no)
 
Do you suffer with pains in your heart or chest? (yes or no)
 
Do you ever feel faint or have spells of dizziness? (yes or no)
 
Do you suffer from high or low blood pressure? (yes or no)
 
Do you suffer from arthritis or other bone/joint problem?
(yes or no)
 
Is there any reason why you should not follow a fitness programme?
 
List any past surgery (Including dates) :
 
List any past serious illnesses (Including dates):
 
List any past injuries (Including dates):
 
List any other minor complaints/injuries which could affect your exercise:
 
Have you ever been limited in your physical activities by a physician? (yes or no)
 
   
Physical History  
Do you take part in any other physical activity/ sport?
 
 
What is the main reason you engage in physical activities?