Questionnaire

THE FITNESS STUDIO

PARTICIPATION QUESTIONNAIRE

Please print this form, complete the questions and hand to your instructor

Name: Age:

E-mail address:

Address:

Telephone/Mobile:

YES

Do you have any type of heart condition?

Do you suffer any chest pain from light activity?

Have you developed any chest pain within the last month?

Are you prone to dizziness or fainting?

Do you have a bone or joint problem, such as arthritis, or an injury, that may be aggravated by light activity? If yes, please give details:

Do you have any type of medical condition, or take any regular medication? If yes, please give details:

If you are female, are you pregnant,

or had a baby within the last 6 weeks?

Do you smoke?

Are you dieting at the moment?

If yes, what type of diet?

Signature: Date:

The Fitness Studio

23 Albion Street Broadstairs Kent CT10 1LU

01843 860960/ 07974 185157