Name Date of birth Age Gender Phone (home) Phone (work) Mobile Phone (emergency) Fax Email Marital Status No of children Occupation Organisation
Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
If you have diabetes (type 1 or type II) have you had trouble controlling your blood glucose in the last 3 months?
Yes No Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise? Yes NoDo you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? Yes No IF YOU HAVE ANSWERED ‘YES’ to any of the questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise. IF YOU ANSWERED ‘NO’ to all of the 7 questions and you have no other concerns about your health, you may proceed to undertake physical activity/exercise. Signature………………………………………………….. Date………………………………………………………………. Health and Medical Profile Regular Doctor Contact Details Last checkup date Reason Blood Type Emergency Contact Have you ever been told by your doctor to avoid any type of exercise or strenuous activity? Yes No If yes, please give details: Are you taking any prescribed medication? Yes No If yes, please give details: Do you smoke? Yes No If yes, how many per day? Do you consume alcohol? Yes No If yes, how many drinks per day? How many hours do you sleep per night? Is this amount satisfactory? Do you have trouble sleeping? Do you have trouble waking up in the morning? Family History Condition Yes/No Relationship to you Fatal/Non HIGH CHOLESTEROL Yes No HIGH BLOOD PRESSURE Yes No ANGINA Yes No HEART ATTACK Yes No STROKE Yes No OBESITY Yes No Your Own History Condition Yes/No/Not Sure Chest Pain Yes No Not Sure Dizziness Yes No Not Sure Fainting Yes No Not Sure High Blood Pressure Yes No Not Sure Joint Problems Yes No Not Sure Pregnant Yes No Not Sure Tuberculosis Yes No Not Sure Bronchitis Yes No Not Sure Asthma Yes No Not Sure Diabetes Yes No Not Sure Rheumatic Fever Yes No Not Sure Nephritis Yes No Not Sure Migraine Yes No Not Sure Epilepsy Yes No Not Sure Are you on any blood pressure medication? Yes No If yes, please give details: Are you currently on any medication that could influence your ability to exercise? Yes No If yes, please give details: Nutrition What do you eat regularly? Breakfast Mid morning snack Lunch Afternoon snack Dinner Evening snack Are you aware of what constitutes as a healthy diet? Yes No Do you currently eat a healthy well balanced diet? Yes No Do you believe you have any problems with your diet at the moment? Yes No If yes, please give details: Do you believe you have any problems with your diet at the moment? Yes No If yes, please give details: Do you drink tea or coffee regularly? Yes No If yes, how many cups per day? How much water do you drink daily? 1-2 glasses 3-4 glasses 5-6 glasses 7-8 glasses Litres consumed per day: Body Image Your perception of your current weight What do you think your ideal weight is? Do you have trouble controlling your weight? Do you feel that it is linked to exercise? Diet? Other Factors? Have you experienced a recent weight variation? Please describe Stable Fluctuating Increasing Decreasing Are you dieting at present? Has your doctor or a family member raised your weight as a medical issue? Activity History What are your usual exercise activities? What is the frequency of your activity? What is the duration of your activity? What is your level of exertion? How long have you been involved in this activity? Do you have any current injuries? If yes, please state Briefly outline your weekly training schedule: Day Activity Duration Intensity Enjoyment MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY History of Participation and Adherence Have you ever had difficulty adhering to an exercise program? Please complete the table below to outline any challenges you may face: Challenges Strengths Weaknesses Commitment to program Time Management Discipline Deadlines Lifestyle/Health Goals List your goals in order of priority: Goal Proposed time frame Obstacles What obstacles may obstruct you from achieving your goals and what are your solutions to combat these? Family: Solution: Lack of support: Solution: Work commitments: Solution: Injury: Solution: Time: Solution: Distance: Solution: Other: Solution:
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