Sign Up -

Name *

Name & Surname

Date of birth

dd/mm/yyyy

Age *

Gender *

M / F

Mobile phone / home Phone *

04xx xxx xxx / home phone

Address

Email *

Emergency Contact *

Name & Contact Mobile

1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke? *

Yes

no

2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise? *

Yes

No

3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? *

Yes

No

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? *

Yes

No

5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months? YES NO *

Yes

No

6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise? *

Yes

No

7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? *

Yes

No

8. Is your doctor currently prescribing drugs (for example, water pills) for high blood pressure or heart condition? *

Yes

No

If you answered YES to questions 1-8, please provide more info here:

Where did you hear about Soutter on the Run? *

Please choose the most relevant

Briefly describe your exercise history *

Anything that would help me understand your situation better

Short term goals

Medium term goals

Long term goals

How important is it that you achieve these goals? (1=not important, 2=somewhat important, 3=quite important, 4moderately important, 10=extremely important)

How long have you had these goals?

Is your family fully supportive of these goals?

Yes

No

What kind of exercise do you prefer?

how many days a week can you train?

What time of day do you prefer to train?

How experienced are you with exercise?

Thank you for completing the sign up questionnaire. By submitting this form your are confirming that the above information is correct and that you wish to hire Michael Soutter as your personal trainer. I will be in contact with you shortly after receipt of this form. Looking forward to working with you. Regards - Coach Michael