Health and Lifestyle Form | Gill Dawson PT & Fitness Coach

Health and Lifestyle History

First name

Last name

Date

Have you ever suffered from any of the following conditions?

Anaemia

Arthritis, rheumatism, or gout

Asthma

Chest pain or angina

Congenital abnormality

Diabetes

Disease of arteries or veins

Epilepsy

Fainting or blackout

Heart attack/palpitations

High blood pressure/cholesterol

Allergies

Loss of consciousness/fainting during exercise

Lung or bronchial disease

Serious accident or injury

Shortness of breath while exercising

Stroke

Surgical operation

Thyroid disease

Backache

Cramp in legs

Headaches

Indigestion

Insomnia

Pregnancy

Swollen or stiff joints

Sport related injury

Other serious illness

Please describe if you answered YES to any of the above

Signature

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If you answer yes to any of these we will discuss and there may be a requirement for you to contact a doctor before commencing a training programme. Please sign to confirm you understand this.

Do you smoke?

How many units of alcohol do you consume a week?

Any other relevant information from client and PT in assessment session.

Health and Lifestyle History

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