Screening Questionnaire

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Name

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Phone Number

DOB (DD/MM/YYYY)

Occupation

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Have you ever had a real or suspected heart attack, coronary occlusion, myocardial infarction, coronary insufficiency, or thrombosis?

YES NO

Have you ever had rheumatic fever?

YES NO

Do you have diabetes, hypertension, or high blood pressure?

YES NO

Does anyone in your family have diabetes, hypertension, or high blood pressure?

YES NO

Has more than one blood relative (parent, sibling, first cousin) had a heart attack or coronary artery disease before the age of 60?

YES NO

Have you ever taken medications or been on a special diet to lower your cholesterol?

YES NO

Have you ever taken digitalis, quinine, or any other drug for your heart?

YES NO

Have you ever taken nitroglycerine or any other tablets for chest pain - tablets you take by placing under the tongue?

YES NO

Are you overweight?

YES NO

Are you under a lot of stress?

YES NO

Do you have a physical condition, impairment or disability, including a joint or muscle problem, that should be considered before you undertake an exercise program?

YES NO

Are you more than 65 years old?

YES NO

Do you exercise fewer than three times per week?

YES NO

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Whether it be a bodyweight workout, a home workout or a free weight session in the gym. I will create a plan to suit your goals, based around your own personal environment.

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