Exercise Program Questionnaire HomeExercise Program Questionnaire Exercise Program Questionnaire Step 1 of 4 - Personal Details 25% PERSONAL DETAILSAll questions marked * below are mandatory, please fill them all out. Name(Required) Email(Required) Date of Birth(Required)Please enter a date in the format (dd-mm-yyyy) DD dash MM dash YYYY Gender(Required)MaleFemaleMembership Type(Required)Standard MembershipStudent MembershipPensioner Membership MEDICAL DETAILSAll questions marked * below are mandatory, please fill them all out. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?(Required) Yes No As you answered YES to the question above, please provide more detail(Required) LIFESTYLE INFORMATIONAll questions marked * below are mandatory, please fill them all out. To get the most out of your membership we highly recommend you book an Individual Personal Program Setup. This will comprise of three sessions with a trainer who will analyse your current level of fitness, discuss your goals & targets, and design a personalised program for you to follow. The cost for this will be $130 and will be added to your first direct debit payment.(Required) Yes No Are you interested in Personal Training sessions?(Required) Yes No Are you training for a specific sport or event?(Required) Yes No As you are training for a specific sport or event, please specify:(Required)Do you have any exercise dislikes?(Required) Yes No Please specify the exercises you dislike:(Required) Questionnaire CompleteAll questions marked * below are mandatory, please fill them all out. I believe that to the best of my knowledge, all of the information I have supplied within this form is correct.(Required) Yes After clicking the continue button below in this Questionnaire, you will be redirected to Pay Smart to finalise your signup
