Saha Lifestyle Questionnaire

Name

Email Address*

Date Of Birth

Address

Are you currently seeing any doctor? If yes, please provide detail,

Address

In case of emergency, whom may we contact?

Relationship

Phone Number

Have you or do you suffer from any of the following. (Please tick & give details where applicable) Choose Any

Heart Palpitations

High Cholesterol

Heart Disease

Angina

High Blood Pressure

Low Blood Pressure

Shortness of breath

Constipation

Frequent Colds

Dizziness/fainting

Headaches

Migraines

Joint Pain

Asthma

Epilepsy

Rheumatic Fever

Arthritis

Other injury/ Health Issue:

Do you currently have or have you previously experienced any of the following,

Surgery

Broken bones(Fractures)

Sprains

Back pain

Long term muscle soreness

Tingling or numbness

Stabbing pain

Painful joints

If yes, please explain more detail below,

Are you under any medication for the above issue?

When do you feel the pain worse? (Eg, siting, bending, flexing)

How did it happen?

What is your occupation and does the above issue affect your daily life?

How much time do you spend sitting each day?

Less than an hour

1 to 2 hours

2 to 3 hours

More than 4 hours

How many hours of sleep do you get everyday?

1 to 3 hours

3 to 6 hours

6 to 8 hours

more than 9 hours

Do you consider yourself to be under stress? If YES, provide details?

How often do you take part in physical exercise?

1 to 2times/week

3 to 4times/week

5 to 6times/week

more than 7times/week

What activity are you currently involved in?

Cardio/ sports

Resistence Training(Hyperthrophy, Strength Training)

Endurance Training (circuit training, HIIT)

Flexibility eg, Yoga

For other activities involved, Please fill in below.

Have you ever had a personal trainer? If yes, provide details of when and for how long?

Do you drink alcohol?

No

1 to 2 times a week

3 to 4 times a week

5 to 7 times a week

Do you have any food intolerances that you know of?

Do you usually control your diet? If yes please specify which type of diet you had already tried.

What do you typically consume for your daily meals?

What are your fitness goals?

Strength Training

Hypertrophy

Weight Loss

General Health

Flexibility

Agility

Rehab

Reduce Stress

Performance

Please specify why do you want to reach your fitness goal?

DECLARATION: By clicking “SUBMIT button”.I declare that the answers I have given are to the best of my knowledge, true and that I have not withheld any material information that may influence the assessment and I also understand that fitness assessment involve health risk/injuries and will not hold SF Fitness coaches against any liability or claims for any injury during or after fitness assessment. I confirm that there has been no change in my health status since the completion of this questionnaire. All information will be kept confidential.*

I agree