HEALTH QUESTIONNAIRE

➊ Your personal details

* Indicates required field

Full name *

First

Last

Date of birth (DD/MM/YYYY) *

Address *

Email *

Phone Number *

Emergency Contact *

First

Last

Phone Number *

❷ About your fitness goals

1. What is your main fitness goal? *

3. What muscle area would you like to focus on? *

Full body Lower body Upper body Core

6. What is the highest level of intensity that you like to go? *

7. Trainer preference: *

Female Male Happy with both

Give us more details of your goals and preferences: *

❸ About your physical state

8. Do you have any muscle, bone, tendon, ligament or joint problems that you have been told could be made worse by participating in exercise? *

Yes No

Please provide details: *

9. Do you have any conditions that may require special consideration for you to exercise? *

Yes No

Please provide details: *

10. Are you currently taking prescribed medication for any condition? *

Yes No

Please provide details: *

11. Have you been to the physiotherapist or the hospital for any injury/condition/illness during the last 24 months? *

Yes No

Please provide details: *

12. If you have any injuries or any medical condition, you will be required to get approval from your physiotherapist/doctor before commencing training at Genius Personal Training. *

I will need to get approval first I am good to go

❹ About your general health

13. Have you ever faint, feel dizzy or lose balance during physical activity? *

Yes No

14. Have you ever feel pains or discomfort in your chest at rest or during physical activity? *

Yes No

15. Have you ever had a heart attack? *

Yes No

16. Are you pregnant or have you given birth within the last 12 months? *

Yes No

❺ FEEDBACK & EXPECTATIONS

How can we improve your overall experience? *

How can we improve our training to achieve your fitness results more efficiently? *

Why do you choose us over other gyms? *

If other, tell us how: *

This Pre-Exercise screening tool does not constitute any medical advice. This form is not intended for use to diagnose, treat, cure or prevent any medical conditions, is not intended to be professional advice and is not a substitute for independent health professional advice. Genius Personal Training do not accept liability for any claims, howsoever described, for loss, damage and/or injury in connection with the use of any of the material, or any reliance on the information therein. *

I agree

➊ Your personal details

​❷ About your fitness goals

​❸ About your physical state

​❹ About your general health

​​❺ FEEDBACK & EXPECTATIONS

❷ About your fitness goals

❸ About your physical state

❹ About your general health

❺ FEEDBACK & EXPECTATIONS