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Name | |
Address | |
 | |
Telephone | |
Telephone (Mobile) | |
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Person to call in case of emergency |
Name | |
Telephone | |
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About you |
Date of birth | |
Height | |
Present weight | |
Weight 1 year ago | |
Ideal weight | |
T-shirt size | Small
Medium
Large |
Occupation | |
Number of hours worked per week | 20
21 - 40
41 - 60
Over 60 |
Do you spend more than 40-50% of your day (please select all that apply) | Sitting
Lifting Loads
Standing
Walking
Driving |
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Exercise |
How many days a week do you normally spend at least 20 minutes in moderate to strenuous exercise | 1
2
3
4
5
6
7 |
Describer the type of exercise you take | |
If so, how long have you been participating | |
What activities would you be interested in learning or participating in, in the the future (please select all that apply) | Walking/hiking
Jogging/running
Meditation
Cooking
Pilates
Swimming
Kick Boxing
Nutrition/Dietary requirements | T'ai Chi
Yoga
Relaxation
Cycling
Weight training
Horse riding
Aerobics |
What are the lifestyle changes that you would like to achieve over the next 6 - 12 months | |
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Medical details |
Do you have any of the following conditions (please select all that apply) | Head/neck injury
Hip/pelvis injury
Arthritis
Bone fracture
Shoulder injury
Knee/thigh injury
Swollen joints
Tennis elbow | Arm/elbow injury
Ankle/foot injury
Calcium deposits
Wrist/hand injury
Back pain/injury
Nerve damage
Other considerations |
If you have selected any of the above, please give further details | |
Are these or any other injuries aggravated by exercise | Yes
No |
If yes, please give further details | |
Are you presenty receiving physical therapy? | Yes
No |
Have any family members died of a heart attack before aged 55? | Yes
No |
Please select any of the following you have been diagnosed or treated for by a physician or health professional | Alcoholism
Heart problems
High blood cholesterol
Anemia
Obesity
High BP mental illness | Asthma
Diabetes
Bronchitis
Epilepsy
Cancer |
Are you on any medication at present? | Yes
No |
If yes, please give further details | |
Please select all that apply if you ever experience any of the following | Unusually short of breath
Pain, pressure, heaviness or tightness in the chest area | Severe dizzy spells or fainting
"Skips", palpatations or fast beats in your chest |
Please list any other surgery, medical conditions or minor compaints and give dates | |
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What are your main reasons for joining us on the retreat? | To try new exercise
Improve on your level
Stress reduction
Meet new people
Enjoyment
Improve health | Holiday
Explore the country
Your tutors
Other (please state below) |
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Is this your first retreat? | Yes
No |
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| WAIVER CLAIMS: Although this questionnaire is designed to assist The Kalma Fitness Team when advising on your individual exercise needs and suitability to participate in the scheduled programs, I am aware that The Kalma Fitness team cannot be held responsible for the health of an individual, and that it is my responsibility to consult with a physician prior to commencing any exercise program. I have read and understood the above information. |
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Kalma Fitness, 81 Belsize Park Gardens, London NW3 4UE
E-mail Kalma Fitness | Mobile: 07855 760434 |
