Kids Fitness - Health Questionnaire

Topics: Medicine, Hypertension, Exercise Pages: 2 (365 words) Published: September 11, 2013

1. Answer all questions below by circling YES or NO with each question.
2. Your accurate answers to these questions gives us in-depth knowledge about your ability to be able to
safely undertake Fitness training,

MR / MRS / MS / MISS Given Name: ________________
Family Name: ___________________________

Date of birth: ______ / ______ / ______ Age: _____ Height: _________ cm Weight: _________ kg

Home Address: __________________________________________________________________________

E-mail: __________________________________________ Contact Number: ________________________

How did you hear about us? Friend, Internet, Flyer, Papers, Yellow Pages, Other________

1. Have you EVER had asthma/used inhaler medication/ been troubled by shortness of breath? YES / NO
2. Do you have diabetes or raised blood sugar levels? YES / NO
3. Have you EVER had epilepsy, experienced fits, seizures, convulsions, fainting or blackouts? YES / NO
4. Have you EVER had heart disease, heart murmur or irregular heartbeat? YES / NO
5. Do you experience chest pain or angina? YES / NO
6. Have you EVER been told that you have high blood pressure? YES / NO
7. Have you EVER had any injuries that have led you to see a medical practitioner? YES/NO
8. Have you EVER been diagnosed with hepatitis, HIV or AIDS? YES / NO
9. Have you EVER suffered from mental illness, depression, anxiety or stress? YES / NO
10. Have you EVER suffered from arthritis or...
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