Pre-Exercise Questionnaire

Do you have any of the following conditions? Asthma, Epilepsy, Back problems, Muscle problems, Diabetes (Type 1/2)

Yes

No

Do you have a heart condition and/or have you ever suffered from a stroke?

Yes

No

Do you have high cholesterol or have you been told you do in the past 6 months?

Yes

No

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical exercise?

Yes

No

Do you ever feel faint, dizzy or lose balance during physical exercise?

Yes

No

Do you have any conditions that may require special consideration for you to exercise?

Yes

No

If you answered YES to any of the above questions, please provide more details:

If you answered NO to all of the above questions, please write 'N/A'.

Do you take any medication for a diagnosed condition that has not been listed already?

Yes

No

If you answered YES to the above question, please provide more details:

If you answered NO to all of the above questions, please write 'N/A'.

Do you smoke? (Cigarettes/E-Cigarettes/Vapes)

Yes

No

On Occasion

Have you spent time in the hospital (including day admissions) for any conditions/illness/injury during the last 6 months?

Yes

No

Are you pregnant or have you given birth within the last 12 months?

Yes

No

I have given birth within the last 12 months

Do you have any diagnosed muscle, bone, tendon or ligament problems that could be made worse by participating in exercise?

Yes

No

I am not sure

Please list your previous experience with fitness (within the past 2 years) to help us gauge what you have done before and what help/experience you may have received:

Do you have any previous injuries or anything we need to keep an eye out for?

Other goals (if not selected above):

Do you suffer from any form of mental health? If so, please provide us with more details:

Please read the following statement and sign in agreement as 'The Recipient':

"I (The Recipient), have provided the correct information to YOUR KYND (Bodi Unlimited Pty Ltd) and will hold the responsibility to update them with any changes if they occur. I have re-read the Pre-Exercise Questionnaire and can confirm that I (The Recipient), have provided all true information about my health status and wellbeing."

First name

Last name

Signature

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