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MOVING YOUR MOOD
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MOVEMENT aND LIFESTYLE PRE-SCREENING
Name
*
First Name
Last Name
Email Address
*
Address
*
Phone Number
*
Occupation
Emergency Contact Name
Emergency Contact Number
(###)
###
####
Has a family member, under 60 suffered from heart disease, stroke, raised cholesterol or sudden death?
If yes please provide details.
Are you over 35 and not participated in vigorous exercise?
Are you on any prescribed medications?
If yes please provide details.
Do you have any infectious diseases?
If yes please provide details?
Do you or have you had arthritis?
Yes
No
Do you have or have you had diabetes?
Yes
No
Do you have or have you had cancer?
If yes please provide details.
Yes
No
Do you have or have you had gout?
Yes
No
Do you have or have you had high blood pressure?
Yes
No
Do you have or have you had heart murmers?
Yes
No
Do you have or have you had rheumatic fever?
Yes
No
Do you have or have you had asthma?
Yes
No
Do you have or have you had dizziness?
Yes
No
Do you have or have you had hernias?
Yes
No
Do you have or have you had heart conditions?
Yes
No
Do you have or have you had high cholesterol?
Yes
No
Do you have or have you had a kidney or liver condition?
Yes
No
Do you have or have you had circulation problems?
Yes
No
Have you been diagnosed with a mental condition/illness? If yes please provide details below.
Do you have or have you had epilepsy?
Yes
No
Do you have or have you had heart palpitations?
Yes
No
Do you have or have you had pain in the chest?
Yes
No
Do you have or have you had ulcers?
Yes
No
Do you have or have you had bowel or bladder incontinence?
Yes
No
Have you had any injury, back or joint condition that may be further injured or aggravated by exercise?
Please provide details if yes.
Do you smoke?
Yes
No
Do you have any medical conditions?
If yes please provide details.
Do you have any pain or restrictions in your body?
If yes please provide details.
If there any other conditions that we should be aware of?
If yes please provide details.
Have you recently been pregnant or are planning on falling pregnant?
Are you allergic to anything?
If yes please provide details.
How much water would you drink in a day?
What time do go to sleep at night, and what time do you wake up?
How would you describe your nutrition?
How much alcohol would you drink in a week?
What exercise or sport are you participating in?
Do you have a strong and healthy connection with family and friends?
How would you rate your stress levels at the moment?
1 really bad (very stressed), 5 really good (stress free)
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