HEALTH DECLARATION

HEALTH

DECLARATION

Before filling out the health declaration, please contact us by email at gert@corsagym.ee

This health declaration form helps me as a personal trainer to understand any health conditions you may have (preexisting or current) as well as your lifestyle habits. The content of the form is strictly confidential and will only be used in the context of my work with you as your personal trainer. Its purpose is to prepare a safe, effective and customized plan for you as the customer. The information entered in this health declaration form is stored for a maximum of one month after the conclusion of our work together.

Please enable JavaScript in your browser to complete this form.

Age

Height

Weight

Desired result/weight

How many times a week do you workout or do you plan to train?

Do you understood the purpose of this questionnaire? *

Are you undergoing any medical treatments? *

Have you been prescribed any medication in the past six months? *

If so, which ones?

Do you have any allergies? *

If yes, then what?

Do you have (or have you ever had) heart disease? *

Do you have (or have you ever had) respiratory problems or asthma? *

Do you have high/low blood pressure? *

Do you have diabetes? *

Have you suffered injuries, or experienced pain/discomfort in your joints or muscles (e.g. shoulder pain, stiff neck, knee pain, muscle pain, etc.)? *

Have you had any problems in the past 12 months:

With elbows
With the neck
With the back
With the hips
With the knees
With the feet or ankles

How would you rate your current health and athletic status (1 = very poor, 5 = very good)

Selected Value: 1

How would you rate your stress level (1 = very stressed, 5 = stress free)

Selected Value: 1

What is your daily activity level? Choose the most suitable *

Sedentary (office work, minimal movement)
Relatively active (physical work, sometimes active outside of work)
Active (active free time, regular exercise)
Extremely active (physical work, regular exercise)

How would you rate your current physical condition?

Untrained
Trained
In very good shape

Do you exercise regularly? *

If so, please describe your training as accurately as possible.

Have you worked out with a personal trainer before? *

Please describe your diet. What do you usually eat:

Breakfast

Lunch

Dinner

Between meals

Do you take nutritional supplements? If so, which ones:

Do you follow (or have you followed) a diet in the last year? Which?

Describe a typical day (waking up, breakfast, working hours, meal times, exercise, etc.)

I agree to share my data and understand what it will be used for. *

I agree.

Your name *

First

Last

Email *

Submission date *

Today's date