Thursday, 23 February 2012

Your Exercise and Medical History

Personal Details

Please complete the following questionnaire providing accurate, complete information regarding your medical and exercise history. 'My Fit Project' treats all information collected from you as strictly confidential. The information collected may assist in the monitoring of changes to your health and fitness, and may assist me in monitoring and providing guidelines for your projects. Please refer to the Privacy Policy for more information.

Name: *

Include first and last name.

Date of Birth: *

Email Address?: *

Gender: *

	Male	Female
What gender are you?

Occupation: *

Identifying your occupation provides information on lifestyle factors (stress levels, sedentary occupation, work hours)

Smoking?: *

	Yes	No
Do you smoke? Check yes if you have had more than 1 cigarette in the last 6 months.

Weight: * kg

Height: * cm

Height and weight assist in calculating your current BMI.

Other Injuries/Surgery:

If checked any above, please explain further or list any other body areas that restrict you from exercise.

Other Health Issues:

List here any other health issues that restrict you from certain types of exercise or explain further any issues checked above.

Medical Clearance

If you have indicated that you have a medical/health condition that restricts you from exercise, you must have clearance from a health/medical professional and agree to the Terms and Conditions of use before continuing to register as a member of 'My Fit Project'.

Exercise History - Time: *

	1-2 per wk	3 per wk	4-6 per wk	7-10 per wk	10+ per wk	None
In an average week, how many sessions a week do you currently exercise at a moderate intensity? (1 session = 30min)

Exercise History - Location: *

Where do you currently exercise? Check any that apply.

Exercise History - Other locations:

Add here any other locations where you exercise.

Current Forms of Exercise - Other:

List any other forms of exercise, not mentioned above, that you are currently engaged in. Or specify further.

Current Forms of Exercise - None:

If selected none in the previous question, when was the last time you participated in moderate forms of exercise for at least 30 minutes?

Resistance/Weight Exercise: *

	Yes	No	Unsure
Have you ever completed any weight/resistance training?

Exercise Intensity: *

Other Exercise Goals:

Include any other goals you would like to achieve by joining 'My Fit Project'. Are there any areas that you would like to improve/focus on? Explain.

Goal Reasons: *

Why do you want to achieve the goals listed above? Is there a purpose/end result you are aiming for?

Exercise Hindrances: *

What do you believe is preventing you from achieving your health/fitness goals and maintaining a regular exercise routine? Check any that apply.

Other Exercise Hindrances :

List any other issues/reasons that hinder you in maintaining a regular exercise routine.

How Found?: *

How did you hear about 'My Fit Project'?

Your Review

Thank you for completing this questionnaire and taking the first step in wanting to improve the fitness of your mind and body. As a member, this questionnaire or one similar, may be sent periodically to review your current health/fitness status.