• Health Questionnaire

    All details on this questionnaire will be held private and confidential. This questionnaire is designed to provide us with the necessary information to advise on any areas which may support you on your journey. PLEASE READ THE TERMS AND CONDITIONS at the bottom of the page as they relate to your contract with us.

  • Name*
  • Address
  • Email Address*
  • Phone Number*
  • Date Of Birth*
  • Doctors Name*
  • It may be necessary for me to contact your GP following the outcome of your consultation. Please provide his/her address*
  • Weight in kg
  • Height in meters
  • Dress size (top and bottom)
  • Please describe the main goals you would like to achieve from committing to this program and why you feel that this program is the right choice to achieve these goals.
  • Please describe what you seek to gain from nutritional support for short and long term.
  • Are you
  • MEDICATIONS and SUPPLEMENTS: Do you currently take any over the counter medication, prescribed drugs or vitamin, mineral or herbal supplements? Please detail below: Medication, dose, condition being treated, frequency, duration
  • HEALTH HISTORY: Please make a list here of the health problems you would like to address, how long you have had these problems and what measures you have taken to support them e.g. headaches, 5 years, paracetamol and acupuncture.
  • Do you have any injuries or suffer with pain or limited movement?
  • Has your doctor ever said you have any of the following?
  • Are you recuperating from a recent illness or operation?
  • If yes, please state;
  • How would you rate your stress levels on a scale of 1 to 10 (10 being the highest)?
  • What are your three biggest stressors at the moment?
  • Do you smoke?*
  • If yes, how many per day?
  • Do you drink alcohol?*
  • If yes, how many units per week?
    1 unit = 1 small shot of spirits. 1.5 units = small glass of wine, 2 units = standard glass of wine or low strength beer/cider. 3 units = Large glass of wine or higher strength beer/cider.
  • Are you aware of anything else that may effect your ability to participate in exercise?*
  • If yes, please state;
  • The information stated above is true to the best of my knowledge at the time of completing the form and I agree with the terms as stated below.**
  • Terms

    I have read and understood the above and am aware that if my medical status changes I must inform my instructor immediately. I hereby declare the above information is correct. I acknowledge the advice that I may require consulting my doctor prior to commencing exercise. I confirm that neither Sharon Morrow, New Dimensions Fitness, nor its representatives are responsible to me in the incidence of illness or injury occurring whilst taking part in this coaching programme or as a direct result thereof.

  • Signed*
  • Date*
  • Security Code*

     

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