14Days Weight Reset And Lifestyle Change Program questionaire
Step 1
Please complete the form below so we can send you your personalised plan.
1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
YES
NO
2. Do you feel pain in your chest when you do physical activity?
YES
NO
3. In the past month, have you had a chest pain when you were not doing physical activity?
YES
NO
4. Do you suffer from asthma – if so, do you use inhaler?
YES
NO
5. Are you diabetic?
YES
NO
6. Do you have a bone or joint problem (e.g. back, knee, or hip) that could be made worse by a change in your physical activity?
YES
NO
7. Are you pregnant or have you been pregnant in the last 6 months?
YES
NO
8. Are you currently taking any medication? If yes, what and for what reason?
YES
NO
9. Do you suffer from regular back pain or have you had any back injury?
YES
NO
10. Do you know of any other reason why you shouldn’t exercise?
YES
NO
Chest
Waist
Hips
Right Thigh
Left Thigh
Right Arm
Left Arm
Name
Email
Phone Number
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I have read and understood this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.
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