Consultation form Hale Health Centre Consultation Form This form is used to gather information before a consultation. Step 1 of 4 25% Your InformationName*OccupationYour Age*Please enter a number from 0 to 120.Sex*MaleFemaleEmail* Phone Number*Weight (kgs) Medical informationRegular physical activity is safe for most people. However, some individuals should check with their doctor before they start an exercise program. To help us determine if you should consult with your doctor before starting to exercise at Hale Health please read the following questions carefully and answer each one honestly. All information will be kept confidential.Please tick if you have had any of the following: Arthritis Back/neck pain or injury Lightheaded/dizziness when exercising Fracture/dislocation High/low blood pressure Hernia Liver/kidney condition Asthma/breathing difficulties Diabetic Epilepsy Heart problems Hepatitis Joint pain/problems Stroke Other:If you have any other medical conditions, please specify them here.If answered yes to any of the above questions, please provide details:Are you pregnant?*YesNoWhat trimester?*1st Trimester2nd Trimester3rd TrimesterAre you currently taking any medication?*YesNoIF YES, please list the medication and its purpose:If there is any other KNOWN physical reason that prevent you from participating in an exercise program, please provide details: Fitness Health AssessmentAre you participating in any physical activity now?*YesNoWhat type of exercise? & How often do you exercise?*How long has it been since any regular exercise?*What are your main goals for joining Hale Health?*How many times do you aim to attend the gym per week?How would you rate your health and fitness levels?*Bad / UnfitAverage / MediumGood / Fit Is there any additional information you wish to share with us?Please tick the box* I agree I acknowledge that my trainer is not giving me any medical advice they are just designing a program based on the relevant information listed above. I hereby agree that my trainer and the staff of Hale Health Centre are not liable in any way for any injuries that occurs during or after any session here at Hale Health Centre.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.