(03) 5441 8457
14-18 High St, Bendigo
info@mcquinnsgym.com.au
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SarahTesting
Health Questionnaire
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Name
*
First
Last
Gender
Female
Male
Other
Height
Weight
Your height and weight is useful to us when writing up your training program.
1. Do you have,or have you had, any of the following conditions? (Tick all that apply)
Asthma
Arthritis or Joint Pain
Chest Pain
Diabetes(Type 1)
Diabetes(Type 2)
Difficulty Breathing
Dizziness
Epilepsy
Heart Problems/Disease
Hernia
High Cholesterol
High Blood Pressure
Low Blood Pressure
Osteoporosis
Stroke
Family History of Heart Disease or Stroke
Varicose Veins
Other? Please describe below
1a.
2. Do you have,or have you had, any joint problems, pains or injuries in any of the following areas? (Tick all that apply)
Ankles/feet
Knees
Hips/Pelvis
Lower Back
Shoulders
Neck
Elbows
Wrists
Muscular Pain
Other? Please describe below
2a.
3. Are you currently taking any medication/s?
Yes
No
3a. If Yes, please list
4. Have you had any major surgery during the last 12 months?
Yes
No
4a. If Yes, describe
5. Do you want a training program written up?
*
Yes
No
Only complete the following questions if you wish to have a training program written up for you.
6. How would you rate your fitness?
Very Low
Low
Good
Very Good
7. Are you currently engaged in physical exercise?
Yes
No
7a. If Yes, desrcibe
7b. Current Frequency and Duration
8. If you are not currently exercising, have you ever engaged in physical exercise?
Yes
No
8a. If Yes, when
8b. Previous Frequency and Duration
9. What is your Main Goal
10. How main days a week do you want to train?
11. Are there any body parts you want to focus on?
12. Are there any body parts you don't want to focus on?
Submit
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