Medical & Health Questionnaire

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About
Courses
Booking
Contact

Medical & Health Questionaire

Any enquires please call: +34 641407036

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Gender?(*)

Gender? Male Female

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First Name(*)

Please type your full name.

Last Name(*)

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Phone Number(*)

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Mobile Number

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E-mail(*)

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Date of Birth(*)

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Occupation

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Emergency contact name(*)

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Emergency contact number(*)

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Relationship to you

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Doctor name

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Contact number

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You should consult your doctor prior to any form of exercise programme or physical activity ESPECIALLY IF YOU ARE NOT USED TO ANY EXERCISE

Please provide any details as appropriate

1. Has your doctor ever advised you not to exercise?(*)

1. Has your doctor ever advised you not to exercise? Yes No

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2. Do you exercise currently?(*)

2. Do you exercise currently? Yes No

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3. Do you have asthma? (*)

3. Do you have asthma? Yes No

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4. Do you have diabetes? (*)

4. Do you have diabetes? Yes No

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5. Do you have Emphysema?(*)

5. Do you have Emphysema? Yes No

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6. Have you ever had pneumonia?(*)

6. Have you ever had pneumonia? Yes No

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7. Do you have or ever had heart trouble?(*)

7. Do you have or ever had heart trouble? Yes No

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8. Have you ever had a stroke?(*)

8. Have you ever had a stroke? Yes No

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9. Do you ever have problems breathing? (*)

9. Do you ever have problems breathing? Yes No

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10. Do you have high cholesterol? (*)

10. Do you have high cholesterol? Yes No

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11. Have you ever had a hysterectomy? (*)

11. Have you ever had a hysterectomy? Yes No

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12. Are you pregnant?(*)

12. Are you pregnant? Yes No

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13. Have you recently given birth?(*)

13. Have you recently given birth? Yes No

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14. Do you have high/low blood pressure?(*)

14. Do you have high/low blood pressure? Yes No

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15. Do you ever feel faint during exercise?(*)

15. Do you ever feel faint during exercise? Yes No

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16. Do you take any medication? (*)

16. Do you take any medication? Yes No

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If you have answered yes to any of the questions above please give details

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Do you have Epilepsy? (*)

Do you have Epilepsy? Yes No

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Do you have or had Glandular Fever?(*)

Do you have or had Glandular Fever? Yes No

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Do you have or had a Hernia?(*)

Do you have or had a Hernia? Yes No

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Do you have or had cancer?(*)

Do you have or had cancer? Yes No

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Do you have any Liver or Kidney infection?(*)

Do you have any Liver or Kidney infection? Yes No

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Do you have any infectious diseases?(*)

Do you have any infectious diseases? Yes No

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Have you been hospitalized in the last 12 months?(*)

Have you been hospitalized in the last 12 months? Yes No

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Have you suffered any broken bones in the last 12 months?(*)

Have you suffered any broken bones in the last 12 months? Yes No

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If you have answered yes to any of the questions above please give details

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1. Do you smoke?(*)

1. Do you smoke? Yes No

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2. Have you ever smoked?(*)

2. Have you ever smoked? Yes No

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3. Do you drink? (*)

3. Do you drink? Yes No

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4. Have you arthritis?(*)

4. Have you arthritis? Yes No

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5. Do you suffer from gout?(*)

5. Do you suffer from gout? Yes No

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6. Do you suffer from any allergies?(*)

6. Do you suffer from any allergies? Yes No

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7. Do you have any existing back problems?(*)

7. Do you have any existing back problems? Yes No

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8. Have you ever torn a muscle?(*)

8. Have you ever torn a muscle? Yes No

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9. Have you ever had an embolism?(*)

9. Have you ever had an embolism? Yes No

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10. Have you ever suffered brain injury?(*)

10. Have you ever suffered brain injury? Yes No

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If you have answered yes to any of the questions above please give details

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Current exercise/activity

How many exercise sessions do you participate in a week?(*)

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What is the duration of exercises?(*)

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What is the intensity of exercise?(*)

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If no exercise when was the last time you participated in any exercise?(*)

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Does your job involve a lot of sitting?(*)

Does your job involve a lot of sitting? Yes No

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Does your job involve activity if so what?(*)

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PERSONAL GOALS

What made you book in to Boot Camp Spain?(*)

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What is your goal?(*)

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After your time with us where do you hope your body will be in say 12 months’ time?(*)

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Do you have adequate personal support from family and friends to help you continue your journey with weight loss and fitness?(*)

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If you are after weight loss what is your weight loss goal?(*)

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Do you take any recreational drugs? If so what are they?(*)

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In order to submit the form you will need to offer specific consent(*)

In order to submit the form you will need to offer specific consent Yes

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Verify(*)

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DISCLAIMER: Although the benefits of these sessions are significant, there is always an element of risk involved with any physical activity. These sessions are designed in such a way to minimise the risk of injury. However, you are taking part at your own risk; Boot Camp Spain or anyone associated with Boot Camp Spain will not be held responsible for any damages, injuries or otherwise that may occur as a result of taking part in boot camp sessions. If at any time during a session you feel discomfort or pain, you should notify your instructor immediately. You are strongly invited to ask your instructor any questions that you may have during the rest intervals throughout your sessions. Your participation in these sessions are entirely voluntary and you may opt out at any given time if you so wish. You will be expected to have purchased your own personal insurance prior to attending Boot Camp Spain as you would for a holiday

1,234

Lbs Lost This Year

567"

Inches Lost

89

Guests This Year

10

Years Running

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Medical & Health Questionaire

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