Full Name:
Age:
Gender:
MaleFemaleOtherPrefer not to say
Contact Number:
Email:
1. Has your doctor ever advised against physical activity due to a medical condition?
YesNo
2. Do you experience chest pain during exercise or at rest?
3. Have you ever lost consciousness, fainted, or experienced dizziness while active?
4. Do you have or have you had (check all that apply):
High Blood PressureDiabetesHigh CholesterolAsthma / Breathing DisordersHeart DiseaseArthritisOther
If “Other”, specify:
5. Are you currently taking prescribed medications?
If yes, list:
1. Have you ever suffered from any of the following? (check all that apply)
Herniated / Bulging Disc (Lumbar / Cervical)Sciatica or Nerve CompressionShoulder Pain / Rotator Cuff InjuryNeck Pain / StiffnessLower Back PainKnee Pain (ACL, Meniscus, Patella issues)Ankle or Foot InjuriesHip Pain / Mobility IssuesBroken BonesMuscle Tears or StrainsPostural Issues (Rounded Shoulders, Forward Head, Scoliosis, Flat Feet, etc.)
If “Broken Bones”, specify:
2. Do you currently experience (check all that apply):
Muscle tightness or stiffnessJoint pain during daily activity or workoutsLimited mobility or difficulty in certain movements (e.g., squatting, overhead reach)
If muscle tightness/stiffness, where?
If joint pain, where?
3. Have you undergone surgery or physiotherapy for any injury?
If yes, explain:
4. Average hours of sleep per night:
5. Stress level (1 = very low, 10 = very high):
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