Pre-Screening Health & Fitness Questionnaire

Please fill out our pre-screening questionnaire below for your FREE session.

In order to truly understand your needs and ensure you get the most out of our sessions, we require some information regarding your health, fitness level, past injuries, likes and dislikes.

Please rest assured anything you share with us is completely confidential and will not be shared with any other parties.

"*" indicates required fields

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Your Information

First Name*

Last Name*

Phone*

Email*

Suburb*

State*

Postcode*

Date of birth*

DD slash MM slash YYYY

Gender*

Height (in CM)

Weight (in KG)

Emergency Contact Name*

Emergency Contact Phone*

Do you have any friends or family members who might want to train with you?

Please write down their names and phone numbers and we will get in touch with them.

How did you find out about us?*

Medical Questions

Do you or any direct family members have any of the following (or a history of)?

please check all that apply

Diabetes

Heart problems

Stroke

Chest Pain

High/Low blood pressure

Asthma

Epilepsy

Liver/Kidney condition

High cholesterol/triglycerides

Osteoporosis

None of the above

If you ticked any of the above boxes, please be more specific about each condition.

Have you recently injured any of the following that could affect your ability to exercise?

Head

Neck

Shoulders

Mid/Upper back

Lower back

Torso

Arms

Wrists/Hands

Hips

Upper legs

Knees

Lower legs

Ankles/Feet

Other:

If you ticked any of the above boxes, please be more specific about each condition.

Other Injury? Please describe

Do you have any allergies?

Please be specific

Are you on any medication?

Please be specific

Is there anything further we should know that might affect your ability to train?

Fitness Questions

What best describes your level of physical activity?*

I have been physically inactive for a number of years

I have trained previously but not for a few months

I train on occasion but I am not a 'fitness fanatic'

I train 1-2 times per week

I train 3+ times per week

I am a fitness fanatic

What best describes your level of motivation?*

Not motivated at all, and require someone to push me

Meh, somewhat motivated and if I put my mind to it can achieve my goals

Yep, I am motivated and will get the job done

Hell yeah, bring it... you had me at burpee!

How far can you run?*

What??? I can't remember the last time a ran!

I can run 1km+ but struggle

I can run 1km+ comfortably

I can run 5km+ but struggle

I can run 5km+ comfortably

I run all the time

How long can you plank for?*

<30 seconds

>30 seconds <60 seconds

>60 seconds <90 seconds

>90seconds

Not sure, never counted

Sorry, whats a plank?

How many sit-ups can you do?*

Are you kidding me?

>1 <15

>10 <30

>30

Not sure, never counted

Sorry, what's a sit-up?

How many push-ups can you do?*

Are you kidding me?

>1 <15

>10 <30

>30

Not sure, never counted

Sorry, what's a sit-up?

What best describes your knowledge of a squat?*

What is a squat?

I have done them before but don't really know if im doing them correctly

I am confident with my form

What best describes your knowledge of a lunge?*

What is a lunge?

I have done them before but don't really know if im doing them correctly

I am confident with my form

Flexibility - legs - straighten out your legs in front of you, do not bend your knees, and touch your toes.*

I cant touch my toes

I can just touch my toes if try really hard

I can touch my toe comfortably and hold position for 5 seconds

I can stretch well past my toes

Flexibility - glutes - sit on the ground cross legged, place hands on the floor in front of you, attempt to take your forehead to the ground and outstretch your arms in front of you*

I can barely cross my legs or it is very uncomfortable to do so

i can comfortably cross my legs and just place my hands on the floor

I can comfortably cross my legs and get my head close to the floor but its tough

I can comfortably cross my legs and can get my forehead all the way to the ground

Flexibilty - shoulders - place right arm over the back of your head, resting palm down between your shoulder blades. wrap left arm behind your mid back with palm facing outward. attempt to interlock your hands, forcing your right hand down the centre of your back, and the left hand upward.*

I can barely place my hands in those positions

I can comfortably rest my hands in these positions but cant get much reach

I can just interlock my hands with some difficulty

I can easily interlock my hands

List any exercises or activities that you really enjoy

List any exercises or activities that you dislike

Have you had personal training/group training in the past? and what did you like/dislike about them?

Please be as honest as possible so that we can do our best to meet your needs!

Other Information

What kind of training are you interested in?*

Personal training (1:1)

Semi PT (2:1 or 3:1)

Personalised small group training (10:1)

What days and time are you preferred times to train? please provide all available times.

Specific goals - these should apply to current objectives and what you would like us to help you achieve.*

Lose 1-10kg

Lose 10kg+

Build muscle

Define my abdominals

Define my chest

Define my back

Define my shoulders

Define my calves

Define my bum

Define my legs

Increase lower body flexibility

Increase upper body flexibility

Reduce lower back pain

Reduce knee pain

Reduce shoulder pain

Reduce kneck pain

Run a 5km event

Run a 10km event

Run City to Surf

Run a half Marathon

Run a Marathon

Soft sand running

Boxing fitness

Learn to swim

Intermediate swimming improvement

Be able to comfortably do several push up's

Be able to comfortably do a chin up

Be able to comfortably do several sit up's

Increase my strength for sport

Increase my speed and agility for sport

Stay in shape during my pregnancy

Get back into shape after my pregnancy

Be able to keep up with my kids

Get my bikini body ready for the summer

Get myself in the best shape ever for my wedding

Im a bridesmaid and want to look my best for my friends wedding

Im visiting family I havent seen in ages and want to look great

I want to feel better all over and look great in the mirror

I want to impress an old flame

Please select all that apply

Do you have any further specific goals not listed?

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Declaration and Waiver*

I understand that I am responsible for my own participation in any activities undertaken in Bodytech classes or associated training programs. I Have answered all questions regarding my medical history and treatments truthfully and accurately, and will update Bodytech of any future information which might affect my health and wellbeing in regards to my participation.

I agree

Pre-Screening Health & Fitness Questionnaire

Please fill out our pre-screening questionnaire below for your FREE session.

Your Information

Medical Questions

Fitness Questions

Other Information

Phone

0426 383 825

Email

info@bodytech.com.au

Location

22a O'Sullivan Rd,
Bellevue Hill NSW 2023

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