Exercise and health questionnaire

Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency contact *

First Name

Last Name

Surgery address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Number of times you smoke per day *

None

1–5

5–10

10–15

15–20

20+

Weekly alcohol consumption in units *

- Single shot (25 ml) = 1 unit - Beer (1 pint) = 3 units - Small glass of wine (175 ml) = 2.3 units - Large glass of wine (250 ml) = 3.2 units - Bottle of wine (750 ml) = 9.7 units

None

1–5

5–10

10–15

15–20

20+

Existing health conditions

Heart problems

Diabetes

Epilepsy

Cancer

Asthma

Arthritis

Osteoporosis

Hypertension

Are you pregnant?

Yes

No

Declaration *

I can confirm that to my knowledge, all of the information I have given is correct