Health Questionnaire
Your information will be kept confidential and stored to be in compliance with GDRP.
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Name *
Email *
Phone number *
Date of birth *
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Gender
What is your motivation for joining Seagrass?
Do you feel there is anything getting in the way of you achieving your goals?
 How would you rate your current fitness level
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10 (High)
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How would you rate your motivation and readiness to start exercising?
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10 (High)
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How would you rate your stress levels?
1 (Low)
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10 (High)
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How would you rate your emotional level?
1 (Low)
2
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9
10 (High)
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In Case of Emergency Contact Name:
Relationship to you
Are you currently under a doctor’s care?
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If yes please explain why
Occupation and hours worked per week if applicable
Lifestyle Information
Do you smoke?
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If yes, how many a day?
Are you currently active?
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If yes how many minutes per week and what type of activity?
Medical History
Do you take any medications on a regular basis, if yes please list medications and reasons for taking.
Have you been recently hospitalised, if yes please give the date and reason.
Have you ever received radiotherapy, if so where and how long ago?
Have you had any surgeries, if yes please state why and give dates
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Have you had any accidents or injuries, if yes please state why and give dates
Are you pregnant?
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Do you have or have you had:
Yes
No
High blood pressure
Low blood pressure
High cholesterol
Diabetes
Heart Issues
A stroke
Lightheadedness or fainting
Emphysema
Thyroid or kidney issues
Epilepsy
Asthma
Back pain
Arthritis
Gynecological issues
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Is there anything else you think we should know?
Enviar
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