Name *

First Name

Last Name

Do You Have Any Of The Following:

High Blood Pressure

Cancer

Epilepsy

Regular Smoking

Diabetes

Osteoporosis

Osteoarthritis

Osteoarthritis

Asthma

Recent Surgery

High Cholesterol

Pacemaker

Thyroid Issues

Pregnant

Pregnant

Other

Please Answer The Following

Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?

Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?

Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

If you have diabetes (Type I or Type II), have you had trouble controlling your blood glucose in the last 3 months?

Do you have any undiagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?

Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise?

Please tick any of the following that apply:

Yoga

Crossfit/Olympic Weightlifting/Barbell Squatting/Deadlifting

Regular coffee consumption (1+/day)

Regular alcohol consumption (>1/week)

Cycling (As a form of training)

Long distance running (5+ km at a time)

See a regular allied health professsional (Physio, Chiro, Massage, Osteo)

Follow a vegan diet

Follow a vegetarian diet

Eat grains regularly (>once per day, pasta, corn, bread of any type)

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