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Health Questionnaire
Please complete the following, to the best of your knowledge
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* Indicates required question
Name
Your answer
Which gym will you be attending your training sessions?
Precision Fitness, Bathurst
IntoYou Life Enhancement Centre, Collaroy Plateau
Online
Not sure yet
Clear selection
How did you hear about us?
Your answer
Address
Your answer
Phone Number
Your answer
Email
Your answer
Birthday
Your answer
Emergency Contact (name and phone number)
Your answer
Why have you decided to try out IntoYou? Tell us a little about your history,motivations, goals, and what you'd like to work on.
Your answer
How do you feel on a regular basis?
Tired/Lethargic
1
2
3
4
5
6
7
8
9
10
Full of energy
Clear selection
How healthy do you feel?
Pick up every bug
1
2
3
4
5
6
7
8
9
10
Never get sick
Clear selection
What are your current stress levels?
Maximum stress
1
2
3
4
5
6
7
8
9
10
Totally relaxed
Clear selection
How strong do you feel?
Need help to open screw lids
1
2
3
4
5
6
7
8
9
10
Can lift my own body weight
Clear selection
How fit do you feel?
Get puffed easily
1
2
3
4
5
6
7
8
9
10
Can run up the stairs without puffing
Clear selection
Please provide details of any health professional that you see on a regular basis (eg. Doctor, naturopath, chiropractor); Name and Contact details
By providing this information you are also consenting to us speaking with them about your health history and how itwill affect your training program
Your answer
Has your doctor ever told you that you have a heart condition or have ever suffered a stroke?
*
No
yes
Do you ever have unexplained pains in your chest area at rest or during physical exercise?
*
no
yes
Do you ever feel faint or have spells of dizziness during physical activity or exercise that causes you to lose balance?
*
no
yes
If you have diabetes (type 1 or 2) have you had trouble controlling your blood glucose in the last 3 months?
*
no
yes
Do you have any diagnosed muscle, bone, or joint problems that you have been told could be made worse by participating in physical activity?
*
no
yes
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity?
*
no
yes
If you answered yes to any of the above required questions, please provide details below:
It is also recommended that you see a GP before commencing a program at our gym
Your answer
Age and Gender
We are assessing risk for heart disease in this question
Choose
Female, 65 or younger years old
Female, 66 or older
Male, 55 or younger
Male, 56 or older
Do you smoke?
no
yes
Clear selection
If you answered yes to above, how many do you smoke a day?
Your answer
Describe your current activity levels
Choose
Less than 150 minutes per week
Greater than 150 minutes per week
Option 3
Have you been told that you have high blood pressure?
no
yes
Clear selection
Have you been told that you have high cholesterol?
no
yes
Clear selection
Have you been told that you have high blood sugar?
no
yes
Clear selection
If you've spend time in hospital in the last 12 months, please provide details below.
Your answer
Are you taking any medication(s)
no
yes
Clear selection
Please provide details of medications
Your answer
Please provide details of any condition that is made worse with a particular type of activity.
We will avoid the activities that cause you injury or discomfort
Your answer
What kind of metabolic type are you?
We can do this during your session, if you are unfamiliar with the metabolic types below
Ectomorph (small and delicate bone structure, flat chest, small shoulders, thin, lean muscle mass, finds it hard to gain weight, fast metabolism)
Mesomorph/Ectomorph mix
Mesomorph (athletic, hard body shape with well defined muscles, rectangular body shape, strong, gains muscle easily, gains fat more easily than ectomorphs)
Mesomorph/Endomorph mix
Endomorph (Soft and round body, gains muscle and fat easily, is generally short and stocky, round physique, finds it hard to lose fat, slow metabolism)
Clear selection
Your exercise involves
Choose
Light
Moderate (eg. power walking)
Intermittent heavy breathing (eg. weights, squash, soccer)
Heavy (eg. run, row, crossfit)
None
You exercise for
Choose
Less than 20 minutes
20-30 minutes
More than 30 minutes
None
You exercise
Choose
1-2 times a week
A few times per month
3 to 5 times a week
Daily or almost daily
Not at all
Your daily activities are mainly
Choose
Moderate, eg. sales rep, teacher
Sedentary, eg. office job
Intense, eg. labourer
What do you want to achieve the most
Choose
Weight/fat loss
Muscle gain
Fitness increase
Maintain current form
Rehabilitation
How committed are you to achieving this goal
Lowest
1
2
3
4
5
First priority
Clear selection
When would you like to achieve this by?
Your answer
Are you pregnant?
No
yes
Clear selection
Are you a mother?
Yes
No
Clear selection
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