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Accept terms & conditions

Are you currently under a doctor’s care? YesNo

Do you have any reasons to believe that you should not perform any exercise activity? YesNo

Do you take any medications on a regular basis? YesNo

If yes, please list medications and reasons for taking

Have you been recently hospitalised or had a surgery? YesNo

Are you pregnant? YesNo

Please mention average alcohol intake per week

On a scale of 1-10 describe your stress level

Describe your daily activity levels

Do you Have:

Please answer the best you can

High blood pressure? YesNo

High cholesterol? YesNo

Have parents or siblings who, prior to age 55 had:

If unsure, just answer the best you can

A heart attack? YesNo

High blood pressure? YesNo

High cholesterol? YesNo

Known heart disease? YesNo

Rheumatic heart disease? YesNo

A heart murmur? YesNo

Chest pain with exertion? YesNo

Irregular heart beat or palpitations? YesNo

Lightheadedness or do you faint? YesNo

Unusual shortness of breath? YesNo

Cramping pains in legs or feet? YesNo

Other metabolic disorders (thyroid, kidney, etc.)? YesNo

Back pain: upper, middle, lower? YesNo

Other joint pain (explain on back of form)? YesNo

Muscle pain or an injury (explain on back of Form)? YesNo

I understand and accept the full terms and conditions as stated on this website. I understand and I am aware that Strength, Functional exercises, Running, Aerobic and Anaerobic exercise, Pilates and Stretching including the use of equipment in the outdoors and indoors setting, are potentially hazardous activities:

I give permission to AGFITNESS & HEALTH for the use of my photograph and other media such as films and quotations, on the Company website and Social Media for promotional material and publications, for which it may be suitable.

Par Q Form

Do you Have:

Have parents or siblings who, prior to age 55 had: