Get the Glow PAR Q
Name
Email
Phone
Birthday
Emergency Contact
Number-
What health goals would you like to achieve in 3 months?
How would you describe your general health and fitness?
What type of fitness do you enjoy?
What type of fitness do you least enjoy?
Name 3 things you could do to improve your health?
What are your reasons to start the fitness plan?
MEDICAL HISTORY
Are you currently receiving medical treatment for a diagnosed condition?
yes
no
Have you had a major illness or injury in the last five years?
option 1
no
If yes please give details-
Are you taking any pescription medication?
option 1
no
if yes please give details-
Please indicate if you have ever experienced the following-
Ever get unusually short of breath with very light exertion?
yes
no
Ever have pain, pressure, heaviness or tightness in the chest area?
yes
no
Ever have severe dizzy spells or episodes of fainting?
yes
no
nEver experience palpitations or irregular heartbeats?
option 1
no
Are you currently pregnant or have you given birth in the last 6 months?
option 1
no
Do you have any aches or pains on the body? if yes where?
Are these injuries from exercise?
Please indicate any other health problems you suffer?
I can confirm that all the information I have given is correct
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