Please recognise that it is your responsibility to work directly with your doctor before, during and after seeking a fitness or nutrition consultation. As such, any information provided is not to be followed without the prior approval of your doctor. If you choose to use this information without the prior consent of your doctor, you are agreeing to accept full responsibility for your decision.

Name: *

First

Last

Date of Birth: *

Address: *

Email Address: *

Contact Number: *

Personal Health History:

Please list your present and past health problems (including operations and injuries) in the table below. Please specify if physical training of any sort has been advised against. If you do not state this below, you are agreeing to take full responsibility for your decision to undertake physical training with Swannfitness.

If any of the health issues are on-going, please advise below anything that triggers/worsens them:

Do you smoke? *

• Yes
• No

If yes how much per week?

Do you drink? *

• Yes
• No

If yes how much per week?

Please highlight below how active you are at present: *

• Sedentary
• Moderately Active
• Active
• Athlete

Have you used a gym or similar facility before? *

• Yes
• No

Do you currently undertake regular exercise? Yes / No *

• Yes
• No

If so please state the type of exercise and how often (gym/resistance training cardio):

Do you need a gym induction to show you how to use the resistance machines? *

• Yes
• No

Any other comments, please state here:

Name: *

First

Last

Date: *

Submit