Physical Activity Readiness Questionnaire

Health & Movement Screening Form

All information is kept strictly confidential and stored securely in line with GDPR.

 

Personal Details

Full Name: ___________________________________________

Address: ______________________________________________

 

Telephone: ___________________________________________

Email: _______________________________________________

Emergency Contact (Name & Number): ______________________

 

 

Lifestyle & Background

Age Group:
☐ 16–25 ☐ 25–35 ☐ 35–45 ☐ 45–60 ☐ 60+

How many times per week do you currently exercise?
☐ None ☐ 1–2 ☐ 3–4 ☐ 5–6 ☐ 7+

How did you hear about Gabby Robinson Wellness?

 

 

Health Screening

Please answer YES or NO to the following:

1. Has your doctor ever said you have a heart condition or that you should only do physical activity recommended by a doctor?
   ☐ YES ☐ NO

2. Do you feel pain in your chest during physical activity?
   ☐ YES ☐ NO

3. Have you experienced chest pain when not exercising?
   ☐ YES ☐ NO

4. Do you lose balance due to dizziness, or have you ever fainted?
   ☐ YES ☐ NO

5. Are you currently taking any medication that may affect your ability to exercise?
   ☐ YES ☐ NO
   If yes, please provide details:

 

1. Do you have any joint, muscle, or back problems (including conditions such as scoliosis) that could be affected by exercise?
   ☐ YES ☐ NO
   If yes, please provide details:

 

1. Have you had any recent injuries, surgeries, or ongoing medical conditions?
   ☐ YES ☐ NO
   If yes, please provide details:

 

1. Are you pregnant or have you given birth in the last 12 months?
   ☐ YES ☐ NO
   If yes, please state stage and whether you have been medically cleared for exercise:

 

1. Do you know of any other reason why you should not participate in physical activity?
   ☐ YES ☐ NO
   If yes, please provide details:

 

 

Current Health & Goals

Do you currently experience any pain or discomfort?
(Please include location, intensity, and triggers)

 

 

What are your main goals?
☐ Strength ☐ Mobility ☐ Pain reduction ☐ Fitness ☐ Rehabilitation ☐ Other: ___________

 

Important Information

• If you have answered YES to any of the above questions, you may be advised to seek guidance from your GP or healthcare professional before beginning an exercise programme.

• All sessions are tailored to your individual needs; however, they do not replace medical advice, diagnosis, or treatment.

 

Declaration & Consent

I confirm that:

• The information I have provided is accurate and complete to the best of my knowledge.

• I understand that exercise carries a level of inherent risk and I participate voluntarily.

• I will inform my instructor immediately if my health status changes or if I experience pain or discomfort during sessions.

• I have disclosed all known medical conditions, injuries, and relevant information.

• I understand that sessions provided by Gabby Robinson Wellness are not a substitute for medical care.

Data Protection:
Your personal information will be stored securely and used only for the purpose of delivering safe, effective coaching in accordance with GDPR regulations. It will not be shared with third parties without your consent.

 

Signature: ___________________________________________

Date: _______________________________________________