Health Status QuestionnaireName*Address*D.O.B*AgeHome PhoneMobile*Email* Emergency Contact Name*Emergency Contact Number*Doctor's Name*Doctor's Number*Gender*FemaleMaleChildren0123+Hours worked per week?5-1010-2020-4040-6060+N/AOver 25% of time you spend at work. Do you*Sit?Stand?Walk?How do you sit?How do you stand?How much do you walk?Did anyone in your family die of a heart attack before age 65?*FatherMotherBrotherSisterGrandparentN/AHave you had any operations?*C-SectionHysterectomyDisc removalHip ReplacementOtherN/AIf other, please specifyDo you have pains in your heart and chest?*YesNoN/ADo you often feel faint or have spells of severe dizziness?*YesNoN/ADo you have high/low blood pressure?*YesNoN/ADo you have a bone or joint problem such as arthritis, that has been aggravated by, or may be made worse with exercise?*YesNoN/AIs there a good, physical reason, not mentioned here, why you should not follow an activity programme, even if you wanted to?*YesNoOtherN/AIf other, please specifyAre you currently, or trying to become, pregnant?*YesNoN/AHave you had a miscarriage?*YesNoN/AClient Lifestyle ProfileCurrent Occupation:Is your job stressful?YesSometimesNot at presentNeverN/AWhat percentage of the day do you spend sitting?Do you have repetitive daily movements?YesNoN/ADo you wear high heeled shoes for extended periods?YesNoN/ADo you have any leisure activities? (running, swimming, walking etc.)YesNoN/AIf yes, please state what those activities are:What other hobbies do you have? (i.e., reading, gardening, surfing the net):Client ObjectivesWhat are your goals for this training programme?FlexibilityCore StabilityPostureStrengthOtherIf other, please specify?Do you have a time scale for this goal?Short TermMedium TermLong TermOtherN/AIf other, please provide rough idea of length of time:Is it realistic, and are you willing to work at home, alone, with a routine, to attain your goal?YesNoN/AClient ContractHow many hours, weekly, will you commit to working with your trainer?How many hours, weekly, will you commit to working at your home routine?Do you understand that only consistent adherence to this routine, and quality training time will/may effect change?*Client Informed Consent. Please read carefully and sign: I have fully understood all the questions put to me; I have answered them honestly and to the best of my ability. In return, my own questions have been answered to my complete satisfaction. I fully understand that I must make a personal commitment to this programme in order to achieve my desired goals.Sign*Date*CommentsThis field is for validation purposes and should be left unchanged.