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About Coach Garry
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Regular exercise is associated with many health benefits. Increasing physical activity is safe for most people. However, some individuals should check with a physician before they become more physically active. Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life. Please read each question carefully and answer every question honestly:
Name
*
First
Last
Email
*
Date of birth (DD/MM/YY)
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Are you currently seeing any doctor? If yes, please provide detail,
Doctor name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
In case of emergency, whom may we contact?
*
Indicates required field
Name
*
First
Last
Relationship
*
Phone Number
*
Have you or do you suffer from any of the following.
(Please tick & give details where applicable)
Choose Any
*
Heart Palpitations
High Cholesterol
Heart Disease
Angina
High Blood Pressure
Low Blood Pressure
Shortness of breath
Constipation
Diabetes
Frequent Colds
Dizziness/fainting
Headaches
Migraines
Joint Pain
Asthma
Epilepsy
Rheumatic Fever
Arthritis
Other injury/ Health Issue:
*
Do you suffer from the following issue before /currently?
1. surgery
2. broken bones
3. sprain
4. back pain
5. Soreness, tingling feeling, stabbing pain
6. Painful joints
If yes, please state the “issue” and “body parts“
1st injury
*
2nd injury
*
3rd injury
*
4th injury
*
Are you under any medication for the above issue?
*
When do you feel the pain worse? (Eg, siting, bending, flexing)
*
How did it happen?
*
What is your occupation and does the above issue affect your daily life?
*
How much time do you spend in a seated position?
*
Please select
1hour
2hours
3-5hours
5-7hours
7hours and above
How many hours of sleep do you get everyday?
*
Please select
1hour
2hours
3-4hours
4-5hours
6-7hours
8hours and above
Do you consider yourself to be under stress? If YES, provide details?
*
How often do you take part in physical exercise?
*
Please select
1-2 times/week
3-4 times/week
5-6 times/week
7+ times/week
What activity are you currently involved in?
*
Cardio/ sports
Resistence Training(Hyperthrophy, Strength Training)
Endurance Training (circuit training, HIIT)
Flexibility eg, Yoga
Other Activities
For other activities involved, Please fill in below.
*
Have you ever had a personal trainer? If yes, provide details of when and for how long?
*
Do you drink alcohol?
*
Please select
NO, I don’t drink
1-2 times/week
3-4 times/week
5+ times/week
Do you have any food intolerances that you know of?
*
Do you usually control your diet?
*
What do you typically consume for your daily meals?
Breakfast
*
Lunch
*
Dinner
*
Snack (If any)
*
What are your fitness goals?
*
Strength Training
Hypertrophy
Weight Loss
General Health
Flexibility
Agility
Rehab
Reduce Stress
Performance
Please specify why do you want to reach your fitness goal?
*
DECLARATION
By clicking “SUBMIT button”.I declare that the answers I have given are to the best of my knowledge, true and that I have not withheld any material information that may influence the assessment and I also understand that fitness assessment involve health risk/injuries and will not hold SF Fitness coaches against any liability or claims for any injury during or after fitness assessment. I confirm that there has been no change in my health status since the completion of this questionnaire. All information will be kept confidential.
*
Agree
Submit
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