Appendix H
GENERAL QUESTIONNAIRE

PERSONAL INFORMATION

Name(s): __________________________________Surname:___________¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬-__________________________
Date of Birth: ______________________________Occupation: ___________________________________
Address: _______________________________________________________________________________
__________________________________________ Postcode: ____________________________________
Home Phone: ______________________________Work Phone: __________________________________
Mobile: ___________________________________ Email: _______________________________________

EMERGENCY CONTACT’S
Person Name: ______________________________Relationship to you: ___________________________
Home Phone: ______________________________: Mobile_______________________________________
Your Doctors Name: _________________________Phone: ______________________________________

DIETARY REQUIREMENTS

Are you currently on a diet? If yes, state how long and the reason__________________________________________________________________________
_______________________________________________________________________________
Are you a vegetarian? ________________________________________________________________________________________
________________________________________________________________________________________

Do you eat the recommended 5 a day? YES NO
Do you eat the recommended three meals a day? YES NO

MEDICAL QUESTIOINNAIRE DIETRY
Please CIRCLE ‘YES’ or ‘NO’ response to the following questions:
Are you over the age of 35 years and have been inactive for a period of 6 months or more? YES NO
Have you given birth within the last 6 weeks? YES NO Are you currently pregnant? YES NO
Are you being treated for any infections or infectious diseases? YES NO
Are you taking any prescribed medications? YES NO
Are you receiving any treatment from a doctor, physiotherapist or any other health professional? YES NO
Have you been hospitalised recently? YES NO
Do you smoke? YES NO
How many cigarettes do you smoke per week? _________________________________________
Do you drink? YES NO
How many units per week? _________________________________________________________

Do you have the following conditions (tick those that you do have):
 Palpitations/ Chest Pain
 Heart Condition
 Stroke
 Low or High Blood Pressure
 Raised Cholesterol/ Triglycerides  Blood Disorder
 Diabetes
 Liver/ Kidney Conditions
 Stomach/ Duodenal Ulcer
 Cancer  Gout/ Joints pains and redness
 Dizziness and Fainting
 Epilepsy
 Hernia
 Asthma/ Breathing Condition
If you have listed any of the following conditions of the above, a medical certificate has to be present to the coach prior to any exercise programmes in the interest of personal safety.
Do you currently have, or have you had?:

 Tendon/ Ligament Damage
 Surgery due to Injury
 Broken/ Fractured Bones
 Back/ Neck Pain
 Joint Pain
 Muscular pain
 Dislocation
 Arthritic Pain
If ‘YES’, give further information:
_______________________________________
_______________________________________
_______________________________________

FUTURE GOALS AND PAST HISTORY
What areas would you like help in achieving your