Fitness. Motivation. Coaching | Scotland

Medical History

Prior to beginning our work together, you will need to fill this form out. If you are part of a sports team, please ensure that you make this clear.

Physical Activity Readiness Questionnaire

Please read carefully:

Select YES or NO. If you select any of the ‘yes’ responses below you may need your doctor’s consent before you participate in any physical exercise.

Personal Details

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Has a doctor ever said you have a heart condition and recommended only medically supervised activity?

Do you have chest pain brought on by physical activity?

Have you developed chest pain in the last month?

Do you lose consciousness or fall over as a result of dizziness?

Do you have a bone or joint problem that could be aggravated by physical activity?

Has a doctor recommended medication for your blood pressure or a heart condition?

Are you aware through your own experience or from doctor's advice of any other reason why you should not exercise without medical supervision?

Please outline any other relevant information that may affect your ability to exercise.

Known allergies:

Pre-existing medical conditions:

Current medication:

Electronic signature

I realize that my body’s reaction to exercise is not totally predictable. Should I develop a condition that affects my ability to exercise, I will inform my trainer immediately and stop exercising if necessary. I take full responsibility for monitoring my own physical condition at all times.

I agree to the above terms and conditions

I do NOT agree to the above terms and conditions

Date of agreement

YYYY

In case of emergency

Name of emergency contact