Health and lifestyle questionnaire

Your Details

First name Required

Last name Required

Phone Required

Email Required

Address

Address 1

Address 2

City

Country

County

Postal Code

Lifestyle

Occupation Required

Does your job involve any repetitive movements, activities or postures? ie desk based, lifting, bending etc. Please explain…

Hobbies / sports

Do your hobbies or any sports you play involve repetitive movements, activities or postures? Please explain…

Stress Level: On a scale of 1-10, with 1 being no stress and 10 being overwhelmed, what is your stress level? Required

Please give details of how stresses in life affect you, if at all. ie, poor quality sleep, anxiety, poor digestion, tension in neck & shoulders etc.

Physical Activity

Current Exercise Participation

Have you had to modify or cease any exercise or sport due to injury or illness? Please give details…

Health & Exercise Goals: Which aspects of your health & physical performance would you like to improve? Please tick all that apply to you:

Core Strength

General Strength

Flexibility

Posture

Sports Performance

Stress Management

Sleep

Relaxation

Other - please give details...

Physical Activity Readiness

Please give further details & information on continuing treatment, medication etc.

Please give details of any illnesses or conditions not detailed above:

Please give further details & information on surgery, continuing treatment, medication etc.

Please give details of any physical problems not detailed above

Pre & Post Natal

Please answer all applicable questions.

Are you pregnant or recently given birth?

Yes

If yes how many weeks pregnant or weeks/ months since giving birth?

Please give any further relevant details regarding pregnancy past or present:

Declaration

By submitting this form you agree to the following:

I have completed this questionnaire to the best of my knowledge & have not withheld information that may be relevant. I do not know of any reason why I should not exercise.
I will advise my instructor of any significant changes to my health before commencing a session.
I understand that all exercise carries a risk of injury. I accept responsibility for my own body & will stop exercising if I need to.
I will inform the teacher of any symptoms, physical discomfort or injuries that may arise.
I understand the instructor can accept no liability for personal injury if:
- My doctor has advised against such exercise.
- I fail to observe instruction on safety & technique.
- Injury is caused by the negligence of another participant in the session.
I am happy for Mind Body Maintenance to contact me with details of the services that they offer.
I understand that all client data is protected under the General Data Protection Regulation (GDPR) 2016 & as such will be securely stored & destroyed in accordance with the law.

Please tick to confirm you agree to this declaration Required

I agree