Exercise Program Questionnaire (Online Screening) Step 1 of 3 - Personal Details 33% 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)MaleFemale 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) FINAL STEPSAll 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
