Health questionnaire

I ask everyone to complete this before their first session, so I can plan training that's safe for you.

Print it and bring it to your first session, or we'll fill it in together when you arrive. Please don't email your answers: health details are safer handed to me in person.

Answering yes doesn't mean you can't train. It tells me what to adapt, and sometimes I'll ask you to check with your GP first. How I look after this information is explained in my privacy policy.

Your details

Full name

Date of birth

Phone

Emergency contact name

Emergency contact phone

GP surgery

Your health

Has a doctor ever said you have a heart condition or high blood pressure?
YesNo
Do you get pain in your chest at rest, in daily life or when you exercise?
YesNo
Have you lost your balance through dizziness, or lost consciousness, in the last 12 months?
YesNo
Do you have another long-term condition, such as diabetes, asthma, epilepsy, osteoporosis or a thyroid condition?
YesNo
Do you take any prescribed medication?
YesNo
Do you have a bone, joint or muscle problem, such as in your back, knees, hips or shoulders, that exercise could make worse?
YesNo
Has a doctor ever said you should only exercise under medical supervision?
YesNo
Are you pregnant, or have you given birth in the last 12 months?
YesNo
Have you had surgery in the last 12 months, including a caesarean?
YesNo
Do you have any pelvic floor symptoms, such as leaking, heaviness or pain?
YesNo
Is there anything else about your health or wellbeing I should know?
YesNo

More detail

If you answered yes to any question, please give details

Medication you take

What you'd like to get from training

Declaration

The information I've given is accurate to the best of my knowledge. I'll tell Mani if anything changes. I agree to Mani using it to plan my training safely, as set out in her privacy policy.

Signature

Date