Please complete this form accurately prior to your first session with me. I look forward to training you. Thanks, Fay xx

Full Name *

D.O.B. *

Email *

Phone *

Gender *

Male

Female

Emergency contact number *

Emergency contact name *

Have you had a major illness or injury in the last 5 years? *

Yes

Are you receiving treatment for any diagnosed medical conditions? *

Yes

Are you taking any prescription medication? *

Yes

Please indicate if you ever experience any of the following symptoms? *

Ever get usually short of breath with very light exertion?

Ever have pain, pressure, heaviness or tightness in the chest area?

Regularly have unexplained pain in the abdomen, shoulders or arm?

Ever have severe dizzy spells or episodes of fainting

Regularly get lower leg pain during walking that is relieved by rest?

Ever experience palpitations or irregular heartbeats?

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

None of the above

Please indicate in the box below any aches, pains or problem areas. Please give details of any areas indicated *

Do you have any injuries aggravated by exercise? *

Yes

Are you currently receiving treatment for any structural problems? *

Yes

Please Indicate any other health problems you suffer from which you have not already mentioned. *

I can confirm that I have answered all questions honestly and that the information given is correct. If I have any concerns I will seek medical advise before starting any programme with, Fay, or Hodgson Health, and any other trading name under the Hodgson Brand. I also understand any exercise I do is undertake at my own risk and if I am unsure I will ask Fay or the trainer/instructor at the time. *

I CONFIRM

TYPE NAME IN CAPITALS TO AGREE to the above *