| Introduction | Questionnaire |
This self-assessment questionnaire is designed to help you to assess your own health in the context of vigorous exercise and also to help you to establish your aims in taking up regular exercise.
It is not designed for completion on-line, but it is recommended that you print it and complete it by hand and bring it along to your first class, especially if you identify some health problems. Your instructor will then be able to advise you on how to modify the exercises to suit your condition. The information you provide would, of course, be treated as confidential and would be used only for this specific purpose.
| Your first name: | ............................ | Your last name: | ............................ |
Please answer the following questions by ticking the appropriate boxes.
| FOR YOUR OWN SAFETY | NO | Not Sure | YES | |||
| Have you ever had any back or joint condition or other injury that may be aggravated by vigorous exercise? |
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| Have you ever had any of the following: arthritis, asthma, circulation problems, diabetes, dizziness, epilepsy, hernia, gout or an ulcer? |
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| Have you ever had a heart condition, high blood pressure, rheumatic fever, stroke, high cholesterol, palpitations, murmurs or pains in the chest? |
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| Has your mother or father, brother or sister had any heart problem before the age of 60? |
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| Are you a heavy smoker? |
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| Are you now or have you recently been pregnant? |
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| Are you taking any prescribed medicine? |
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| Is there any other condition that might be a reason to modify your exercise programme? |
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| If you have answered 'yes' or 'not sure' to any of the above questions, then if you have any doubt at all as to whether you should take up vigorous exercise, please check with your doctor or specialist first. | ||||||
| YOUR EXERCISE RÉGIME What regular exercise have you been doing? | ||||||
| None |
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Walking |
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| Aerobics |
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Circuit Training |
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| Sports (please specify) ..................................................... |
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| Other (please specify) ....................................................... |
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| YOUR HEALTH & FITNESS How would you describe your physical condition? | ||||||
| Unfit |
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Underweight |
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| Fit |
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Overweight |
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| Very Fit |
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Healthy |
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| Super Fit |
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Unhealthy |
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| YOUR AIMS What do you want to achieve from exercise? | ||||||
| Improved Fitness |
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Improved Muscle Tone |
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| Maintained Fitness |
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Increased Muscle Size |
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| Loss of Fat |
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Training for Sport |
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| Good Health |
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Social Enjoyment |
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| DECLARATION Please sign the following declaration: | ||||
| I have completed the above questionnaire and I have read and understood all the advice given. I understand that the information I have given is supplied in confidence and will be used only as a basis for exercise advice. | ||||
| Signature: | .......................................... | Date: | .......................................... | |
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