Programs
Zenith Fusion Fat Loss
Rapid Fat Loss Zenith Protocol
One to One Online Coaching
Fit For Life Program
Results
Blog
About
Contact
MY ACCOUNT
Programs
Zenith Fusion Fat Loss
Rapid Fat Loss Zenith Protocol
One to One Online Coaching
Fit For Life Program
Results
Blog
About
Contact
MY ACCOUNT
Home
Programs
Zenith Fusion Fat Loss
Rapid Fat Loss Zenith Protocol
One to One Online Coaching
Fit For Life Program
Results
Blog
About
Contact
My Account
Health Questionnaire
If you could complete this form in as much detail and as accurately as possible it will enable us to create the best possible program for you.
Name
*
First
Last
Date
*
MM slash DD slash YYYY
Email
*
Phone
Sex
*
Male
Female
Prefer Not To Say
Are you/Do you have
Arthritis
Current Smoker
Currently inactive
High Blood Pressure
High cholesterol
Male over 35 or Female over 45
Diabetes
Heart disease in the family (mum/dad etc)
Asthma
Epilepsy
Ankle problems
Knee problems
Hip Problems
Back problems
Neck problems
Shoulder problems
Other
If other, please specify
Do you have or have had?
Hernia
Dizziness
Heart murmur
Rheumatic Fever
Stomach Problems
Liver/Kidney disease
Infectious disease
Gout
Chest pain
Glandular Fever
Chronic illness
Stroke
Heart Condition
Any other conditions that may be worsened by exercise?
Have you been Hospitalised recently?
*
Yes
No
Are you currently?
Pregnant
Given birth recently (within the past 2 months)
Dieting or fasting
On any prescribed medication
If on any medication, please specify
All risks associated with initiating a new fitness program have been fully explained and I understand and accept these risks. Although all attempts will be made to minimise these risks, I do NOT hold your name responsible for any harm that may occur to me should I decide to participate in the program.
*
I confirm I agree with the above
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