Health Questionnaire — Thea Hudson

Section 1

Your details

Full name

Date of birth

Contact number

Email

Address

Emergency contact name

Emergency contact number

Relationship to you

Section 2

Health screening

Please answer Yes or No to each question, and note any detail in the box below.

1.Have you ever been diagnosed with a heart condition, or been treated for high blood pressure?

Yes No

2.Do you have a breathing condition, such as asthma or bronchitis?

Yes No

3.Have you ever had chest pain, including during physical activity?

Yes No

4.Do you ever feel faint or have spells of dizziness?

Yes No

5.Have you ever been diagnosed with a bone or joint condition, for example back or joint pain, that exercise could affect?

Yes No

6.Are you currently taking any medication?

Yes No

7.Are you currently pregnant, or have you given birth in the past year? (If yes, the pregnancy or postpartum version of this form will suit you better, just let me know.)

Yes No

8.Is there any other reason why you should not take part in physical activity?

Yes No

Additional information

If you answered Yes to any of the above, please note medication, reason, or any detail you want me to know.

Section 3

Readiness and lifestyle

These help me tailor your training. Fill in as much as you would like.

What does your training look like now, and what has it looked like in the past?

What are you hoping to achieve, and what would feel like a win for you?

Which types of training do you enjoy, and which do you tend to avoid?

Are there any past injuries or niggles I should know about?

Do any work or home commitments affect the time you can give to training right now?

On a scale of 1 to 10, how would you rate your current focus and motivation?

Informed consent

Informed consent

Signature (type your full name)

Date

I confirm the typed name above is my electronic signature, and that the information I have provided is accurate to the best of my knowledge.

Optional

Stay in touch

I would like to receive occasional news and updates from Thea Hudson. My details will never be shared with a third party.