Nutrition and Exercise Questionnaire
The more information we can receive before the course the more beneficial we can make the course for you.  However if you do not want to enclose some information we will understand.  All information will be kept confidential.
Are you a vegetarian?
Yes No
Do you eat fish?
Yes No
Are you a vegan?
Yes No
Are you gluten intolerant?
Yes No
Are you wheat intolerant?
Yes No
Are you lactose intolerant?
Yes No
Do you have a nut allergy?
Yes No
Do you have any other food intolerances or allergies?
Yes No

If so, please state them below.
Any other information.
Do you currently exercise?
Yes No
If yes, please state which exercises you do and how frequently.
What exercise have you done in the past?
What is your date of birth?
What is your current weight?
What do you believe is your healthy weight?
What is your height?
Telephone number:


FitFarms Physical Activity Readiness Questionnaire
Please fill in the questionnaire below as accurately as you can by putting stars in the boxes. If you say yes to any of the questions, it does not mean you cannot join us at FitFarms it just means you will need to see your doctor before you join us.
1.  
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes No
2.  
Do you ever feel pain in your chest when you do physical activity?
Yes No
3.  
Have you ever had any chest pains?
Yes No
4.  
Do you ever feel faint or have spells of dizziness
Yes No
5.  
Do you have a joint problem that could be made worse by exercise?
Yes No
6.  
Have you ever been told that you have high blood pressure?
Yes No
7.  
Are you currently taking any medication of which FitFarms should be made aware?
Yes No

If so, please describe below.
8.  
Are you pregnant or have had a baby in the last six months?
Yes No
9.  
Is there any reason why you should not participate in physical activity?
Yes No
10. 
Have you had any major or minor operations that FitFarms should be made aware of?
Yes No

If so, please describe below.

If you have answered yes to one or more questions
Talk to your Doctor and describe FitFarms and the exercises that you will be participating in. Tell your Doctor about the questionnaire and which question(s) you answered yes to. If you would like FitFarms to speak to your Doctor we will be happy to do so.
If you have answered no to all questions
You can be reasonably sure that it is safe to join us at FitFarms.
Please note
If your health changes so that subsequently you answer yes to any of the above questions, please inform us immediately. If you become unwell because of a temporary illness such as cold or flu contact us immediately.


Other Information
Information below is important. Please do not leave them blank.
What is your full name?
Your Email Address
Next of Kin
Their Address
Their Contact No.