SCULPT PRE-TRAINING QUESTIONNAIRE:

PERSONAL DATA:

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SCULPT PRE-TRAINING QUESTIONNAIRE

To register, please take the time to fill out the information below.

1. GENERAL MEDICAL INFORMATION:

1.1 Do you have any known illnesses or medical conditions at present or any under investigation?  If yes, please provide details including any current treatment you are undertaking

1.2 Are you on any medication or undertaking any therapy for a diagnosed condition?

1.3 Have you ever been admitted to or received treatment from hospital, for any reason in the last 5 years?    If yes, please provide dates, hospital details and reasons:

1.4 Have you been absent from work due to illness in the last two years If so, why and how for how long?

1.5 Do you have any recurring medical, surgical or emotional problems? If yes, please provide details below even if you currently aren’t suffering from them.

1.6 Are you a registered disabled person? If so, please give details of the nature of your disability.

1.7 Do you smoke? If so, please provide details:

1.8 Any additional information:

CARDIOVASCULAR SYSTEM

(Do you currently have or have had in the past 5 years.)

2.1 Heart disease or blood pressure problems – low and high?

2.2 Shortness of breath/chest condition including pain? 

2.3 Metabolic issues - Type 1 or Type 2 Diabetes. 

2.4 Have you been diagnosed with Anemia?

2.5 If answered yes to any     

       questions, are these

       impacted / affected by

       exercise or impair your

       ability to exercise?

RESPIRATORY SYSTEM:

(Do you currently have or have had in the past 5 years)

3.1 Suffered from shortness of breath when not exercising

3.2 Lung conditions including cystic fibrosis?

3.3 Asthma – if yes what medications are you taking?

3.4 If answered yes to any 

      questions, are these

      impacted / affected by

      exercise or impair your

      ability to exercise?

DIGESTIVE SYSTEM:

(Do you currently have or have had in the past 5 years)

4.1 Nausea, indigestion or ulcer?

4.2 Medicated food allergies that have an autoimmune response (IGE)?

4.3 Crohn's disease or Celiac's disease?

4.4 If answered yes to any

       questions, are these

       impacted / affected by

       exercise or impair your

       ability to exercise?

CENTRAL NERVOUS SYSTEM:

(Do you currently have or have had in the past 5 years)

5.1 Suffer from blackouts, fainting or giddiness?

5.2 Light Headedness or dizziness?

5.3 Regular migraines or headaches?

5.4 If answered yes to any

       questions, are these

       impacted / affected by

       exercise or impair your

       ability to exercise?

REPRODUCTIVE / URINARY SYSTEM:

6.1 Are you pregnant or is it possible that you may be pregnant?

6.2 Have you given birth in the past 12 months?

6.3 If yes, are you recovering from a C-Section?

6.4 Are you experiencing any symptoms of Menopause or taking medications for

       Menopause?

6.5 Do you have Polycystic Ovary Syndrome, Endometriosis or any other diagnosed

       medical condition pertaining to your gender?

6.6 Do you have any kidney issues including Chronic Kidney Disease?

6.7 Any bladder issues?

6.8 If answered yes to any

       questions, are these

       impacted / affected by

       exercise or impair your

       ability to exercise?

MENTAL WELL-BEING:

7.1 Are you suffering with or have been diagnosed in past 5 years with depression

       including post-natal? If so, please require details including any therapies and

       medications and if you are still under care for this condition?

7.2 Have you been diagnosed or affected by – bipolar, schizophrenia, seasonal

       effectiveness disorder, mania, stress or anxiety that has required medical

       intervention or support? If so, please require details including any therapies and

       medications and if you are still under care for this condition?

7.3 Have you had an eating disorder such as bulimia or anorexia? Or suffered from

       body dysmorphia? If so, please require details including any therapies and

       medications and if you are still under care for this condition?

7.4 Have you consulted a psychiatrist or psychologist in the past 12 months?

7.5 Have you ever used or required treatment or counselling for any form of

       chemical substance, abuse or dependency, including alcohol, tranquillisers,

       solvents or illegal drugs? If yes, please give details?

7.6 If answered yes to any

       questions, are these

       impacted / affected by

       exercise or impair your

       ability to exercise?

MUSCULOSKELETAL SYSTEM:

8.1 Do you have a back condition? Please detail any back issues including any

       condition you are in recovery from.

8.2 Have you pulled any ligaments, tendons or have any muscle conditions or

        injuries in the past 12 months?

8.3 Any issues with hips, knees, or joints? Please detail including any mobility issues.

8.4 Do you have a hernia or recovering from one?

8.5 Do you suffer from osteoporosis, arthritis, or joint / bone conditions? 

8.6 Do you suffer from fibromyalgia? If yes, please give details.

8.7 Do you have muscle cramps, tingling in limbs, or circulatory issues that affect

       you day to day?

8.8 If answered yes to any

       questions, are these

       impacted / affected by

       exercise or impair your

       ability to exercise?

ENDOCRINE SYSTEM:

9.1 Do you have a diagnosed thyroid condition (including under / over active

       Thyroid syndrome)

9.2 Do you have a diagnosed adrenal condition including ASF (Adrenal Stress

       Fatigue)

9.3 If answered yes to any

       questions, are these

       impacted / affected by

       exercise or impair your

      ability to exercise?

DECLARATION:

I declare that, to the best of my knowledge, this is true declaration of the state of my health. I note that any misrepresentation or non-disclosure of facts may result in my booking being cancelled.  I also agree to my General practitioner being approached for further information.

 

This form will be kept on your file and the information in it will only be used where necessary.

I hereby give my consent for this information to be recorded and used in this way.

 

Before returning this form, please re-read and check all questions are answered accurately.

 

I authorise my doctor and dentist to release to Sculpt Personal Training all and any details of my medical records.