Fitness Assessment | Wellbeing Wayfinder

First name

Last name

Email

Phone

Date of Birth

Day

Month

Year

Emergency Contact Name

Emergency Contact Phone

1. Has a doctor ever told you that you have a heart condition, or that you should only do physical activity recommended by a doctor?

Yes

No

2. Do you ever feel pain or discomfort in your chest during physical activity?

Yes

No

3. In the past month, have you had chest pain while at rest or not exercising?

Yes

No

4. Do you lose your balance due to dizziness, or have you lost consciousness in the last 12 months?

Yes

No

5. Do you have a bone, joint, or soft tissue problem that could be made worse by a change in your physical activity?

Yes

No

6. Is your doctor currently prescribing medication for your blood pressure, a heart condition, or diabetes?

Yes

No

7. Do you know of any other reason why you should not engage in physical activity without medical supervision?

Yes

No

What is your current activity level?

Sedentary / rarely active

Lightly active

Moderately active

Very active

Are you currently pregnant, or have you given birth in the last 6 months?

Yes

No

Not applicable

Previous injuries or surgeries (write 'None' if not applicable)

Diagnosed medical conditions (write 'None' if not applicable)

What are your main goals for training?

Anything else you'd like us to know?

I confirm the information provided is accurate to the best of my knowledge. I understand that participating in physical activity carries some risk, and I take part at my own responsibility. If I answered 'yes' to any health screening question, I understand I may be advised to consult my GP before continuing.

Signature (confirming the above declaration)

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Date

Day

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