Staff Pre-Exercise Questionnaire

Personal Details

Name*

First Last

DOB*

Age

Sex

Address

Street Address Suburb Postcode

Preferred Contact Number*

Email*

Occupation

Name*

First Last

Relationship*

Preferred Contact Number*

Has anyone in your family under 60 suffered a heart attack, stroke, raised cholesterol or sudden death?*

If yes, please provide details and approximate date cleared.

Are you a male over 35 or female over 45 not used to regular exercise?*

If yes, please provide details about your current exercise routine.

Have you been hospitalised recently?*

If yes, please provide details and approximate date cleared.

Do you have a heart condition?*