New Client Details

First name

Last name

Address

Email

Phone

Date Of Birth

Day

Month

Year

Emergency Contact and Details

Doctors Name, Surgery and Contact Details

PAR-Q Physical Activity Readiness Questionnaire.

If you answer yes to any of the questions you may be asked to get a note from your doctor to confirm your ability to train safely.

Have you ever suffered with Heart Issues? Eg Heart Attacks, Arrythmia, Angina, Palpitations, Chest Pain or Dizziness etc.

Do you suffer from High or Low Blood Pressure?

Do you have any Chest Conditions? Eg Asthma, Bronchitis, Claudication, etc.

Do you have any Blood Vessel or Circulation Issues? Eg Thromosis, Stroke, Anneurisms, Claudication, Dizzy Spells, etc.

Have you had any history of Major Illness in your Life? Eg Cancer, Inflammatory Diseases, Blood Disorders etc.

Have you been diagnosed with any Neurological Diseases? Eg Parkinsons, Dementia, Alzheimers, MS, etc.

Do you suffer fro Diabetes/ Please state whether you are insulin dependent.

Do you have a history of Psychiatric or Emotional Conditions? Eg Depression, Anxiirty,etc.

Do you have any problems with your Bones? Osteoporosis,

Have you had surgery on any joints? If so give details, When What Where etc.

Did you have any surgery on your joints?

Have you had any Back Problems?

Have you any Physical Disabilities, including Sight, Hearing etc.

Do you suffer from Arthritis? If so state where is affected and level of pain.

Do you take medication regularly? Please state what and dosage (include prescribed and non prescribed).

Have you suffered any falls in the last 2 years? If so please give details.

Do you have any problems Eating or Drinking?

Do you smoke?

Yes

No

Do you drink alcohol?

Yes

No

In the past week how much pain have you been in?

Waiver / GDPR Agreements

Please tick each statement below to show you agree.

I have answered all questions honestly and to the best of my knowledge and any questions I asked were answered to my full satisfaction.

I agree.

I accept that there are dangers and risks that are inherent to taking part in Physical Exercises and declare that I know no reason why I am not fit and ready to take part in an exercises programme.

I agree.

I consent to my health data being used for the purpose of my wellbeing.

I consent to my health data being stored in lines with current GDPR regulations.

I agree.

Client Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Day

Month

Year

KEEPING FIT.
Starts here.

Motivating Harrogate, Ripon, Boroughbridge, Knaresborough and Nidderdale areas, for 10 years.

KEEPING FIT.
Starts here.

Motivating Harrogate, Ripon, Boroughbridge, Knaresborough and Nidderdale areas, for 10 years.

KEEPING FIT.
Starts here.

Motivating Harrogate, Ripon, Boroughbridge, Knaresborough and Nidderdale areas, for 10 years.

KEEPING FIT.
Starts here.

Motivating Harrogate, Ripon, Boroughbridge, Knaresborough and Nidderdale areas, for 10 years.

Exercise - AdaPT - OVERCOME

New Client Details

PAR-Q Physical Activity Readiness Questionnaire.

Waiver / GDPR Agreements