Questionnaire

Name  *

Address  *

Age:  *

Email  *

Gender:  *
male
female

Weight kgs:  *

Are you male over 35 or female over 45 and not used to regular exercise?  *
Yes
No

Have you been hospitalised recently?  *
Yes
No

Are you currently taking any medication?  *
Yes
No

Are you pregnant?  *
Yes
No

Is your blood pressure higher than 130/90?  *
Yes
No

Do you have any heart condition?  *
Yes
No

Have you ever had a stroke?  *
Yes
No

Do you have Type I or Type II Diabetes?  *
Yes
No

Do you have epilepsy?  *
Yes
No

Have you had a hernia?  *
Yes
No

Do you suffer from dizziness or fainting?  *
Yes
No

Do you have high cholesterol?  *
Yes
No

Do you have arthritis?  *
Yes
No

Do you suffer from asthma?  *
Yes
No

Do you get muscle cramps or joint pain?  *
Yes
No

Do you smoke?  *
Yes
No

Are you currently dieting of fasting?  *
Yes
No

Have you ever had an injury to your neck?  *
Yes
No

Have you ever had an injury to your back?  *
Yes
No

Have you ever had an injury to either shoulder?  *
Yes
No

Have you ever had an injury to either elbow?  *
Yes
No

Have you ever had an injury to either hip?  *
Yes
No

Have you ever had an injury to either knee?  *
Yes
No

Have you ever had an injury to either ankle?  *
Yes
No

Please provide some brief information about any injuries or conditions that would require us to modify your program?  *

How many surf sessions do you get in a month?  *
  1-5
  5-10
  10-20
  20+

How would you describe you surfing ability?  *
  Beginner
  Intermediate
  Advanced

How would you describe your overall fitness?  *
  poor
  good
  very good
  excellent

What is your recent exercise history?  *

What equipment would you prefer to use in your program? Note: only indicate the equipment that you will have available or have purchased?  *
  exercise ball
  balance pad

Generally, how many days are you planning to exercise each week? ( excluding surf sessions )  *
  1
  2
  3

What areas of your fitness would you like to improve?  *
  balance
  strength
  agility
  flexibility
  endurance
  all of the above

What parts of your body do you wish to concentrate on the most?  *
  chest
  back
  shoulders
  arms
  hips / backside
  legs
  stomach / abs
  lower back
  all of the above

How did you hear about fit2surf.com.au?  *
 A friend
 Internet Search
 Advertising


I have answered the above questions truthfully and I have no known medical conditions that would prevent me from undertaking an exercise program and do so solely at my own risk. I understand that the exercises contained in the program are to be used as a guide only. 

I understand that no exercise or activity should be undertaken without prior consultation with a medical practitioner.

If I have answered yes to any of the above questions, I have had prior clearance from my doctor to undertake an exercise program.

 

 *
 I Agree

 
 

 

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