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Seniors Fitness Online Health Questionnaire

To enable appropriate modification of the program, please indicate if you have any of the following medical conditions and provide further detail as necessary:

Osteoarthritis/Rheumatoid Arthritis

Type 1 diabetes

Type 2 diabetes

Hypertension (high blood pressure)

Ischemic Heart disease

Cancer

Spinal Stenosis / Spinal surgery

Chronis lower back pain

Gait and balance disorders

Parkinson's disease

Dementia (please specifiy bellow)

Stable angina

Stable congestive heart failure

Patient on chronic corticosteroid therapy

Cerebral vascular accident

Depression

Anxiety

History of fracture

Epilepsy

Hip/knee replacement

Incontinence

High cholesterol

Further information / Other relevant medical conditions:

Current Medications

1. Do you have any injuries that may affect your ability to exercise? If so, please give detail.

2. Do you have or have you ever had any back pain? If so, please give detail.

3. How often do you have a drink containing alcohol?

4. Do you smoke or have you quit smoking in the last 12 months?

5. How often do you exercise and what do you do?

6. Do you ever feel any Shortness of breath or pain in your chest when exercising? If so, please give detail.

7. What do you hope to achieve from this program?

Measurements

Height (cm)

Weight (kgs)

Waist circumference

Hip circumference

Overall Wellbeing

1. How satisfied are you with your perceived level of physical fitness? Very Dissatisfied ---1---2---3---4---5---6---7---8---9---10--- Very Satisfied

2. How satisfied are you with your current level of exercises? Very Dissatisfied ---1---2---3---4---5---6---7---8---9---10--- Very Satisfied

I have read and accept Seniors Fitness Privacy Policy

I have read and accept Seniors Fitness terms & conditions

I declare that I have understood this form, that all information detailed above is true to the best of my knowledge and I have informed Seniors Fitness of all existing health information. I will inform Seniors Fitness of any new or changes in my health conditions.

Thanks for submitting your health questionnaire. Someone from Seniors Fitness will be in contact with you shortly!

© 2017 by Seniors Fitness.

CONTACT

US

Tel. (02) 8056 2357

contact@seniorsfitness.net.au

fax: (02) 9012 0616

Level 5, Suite 505, 35-45 Spring St,
Bondi Junction, NSW 2022

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US

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8:30am Saturday

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Monday- Friday 8am-5pm

Saturday 8:30am-11am

Sunday: Closed

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