Health Status QuestionnaireName* Address*D.O.B* Age Home Phone Mobile* Email* Emergency Contact Name* Emergency Contact Number* Doctor's Name* Doctor's Number* Gender* Female Male Children 0 1 2 3+ Hours worked per week? 5-10 10-20 20-40 40-60 60+ N/A Over 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?* Father Mother Brother Sister Grandparent N/A Have you had any operations?* C-Section Hysterectomy Disc removal Hip Replacement Other N/A If other, please specify Do you have pains in your heart and chest?* Yes No N/A Do you often feel faint or have spells of severe dizziness?* Yes No N/A Do you have high/low blood pressure?* Yes No N/A Do you have a bone or joint problem such as arthritis, that has been aggravated by, or may be made worse with exercise?* Yes No N/A Is there a good, physical reason, not mentioned here, why you should not follow an activity programme, even if you wanted to?* Yes No Other N/A If other, please specify Are you currently, or trying to become, pregnant?* Yes No N/A Have you had a miscarriage?* Yes No N/A Client Lifestyle ProfileCurrent Occupation: Is your job stressful? Yes Sometimes Not at present Never N/A What percentage of the day do you spend sitting? Do you have repetitive daily movements? Yes No N/A Do you wear high heeled shoes for extended periods? Yes No N/A Do you have any leisure activities? (running, swimming, walking etc.) Yes No N/A If 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? Flexibility Core Stability Posture Strength Other If other, please specify?Do you have a time scale for this goal? Short Term Medium Term Long Term Other N/A If 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? Yes No N/A Client 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* NameThis field is for validation purposes and should be left unchanged.