Consultation | Hale Health Centre

Medical information
Regular 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?*
- Yes
- No
What trimester?*
Are you currently taking any medication?*
- Yes
- No
IF 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 Assessment
Are you participating in any physical activity now?*
- Yes
- No
What 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 / Unfit
- Average / Medium
- Good / 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.
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Consultation form