Questionaire - Healthy Living And You

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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