Questionnaire

Please ensure you fill out this questionnaire with as much detail as possible, as it’s designed to help customise the service to better suit your needs.

Questionnaire

Please ensure you fill out this questionnaire
with as much detail as possible, as it’s designed
to help customise the service to better suit
your needs.

Please enable JavaScript in your browser to complete this form.

Name

First

Last

Contact Number

Emergency Contact Name

First

Last

Emergency Contact Number

Occupation

Do you spend more than 25% of your working time:

Date of Birth

On a scale of 1-10 how would you rate you general energy level

Do you have any injuries? (Specify)

Health related goals you'd like to achieve over the next 6 months?

Long term health and fitness goals?

On a scale of 1-10 (1 being very unfit, 10 being extremely fit) how would you asses your fitness?

Can you walk briskly without fatigue?

Can you jog 3 miles continuously at a moderate pace without discomfort?

Are you currently exercising? If so, what type?

What do you see as the main barriers that prevent you from exercising as you would like?

Do you follow any particular diet?

How many days a week do you want a personal trainer?

How many days a week (including personal training) can you commit to training?

Do you have any injuries?

If yes, does exercise aggravate the injury? If so how?

Do you consent to occasionally having videos or photos taken for our marketing materials, with efforts made to conceal your face?

I would like to engage voluntarily in an exercise programme designed by Syz and Fitness to improve my health. I understand that the activities are designed to place a gradually increasing workload on the cardio-respiratory system and thereby improve its function. The reaction of the cardio-respiratory system cannot be predicted with complete accuracy. There is a risk that changes might occur during exercise to the blood pressure or heart rate. I understand that the purpose of the exercise programme is to improve the cardio-respiratory system, body composition, flexibility, muscular strength and endurance. A specific programme will be given to me based on the information given. All exercise programmes include warm up, exercise at target heart rates and cool down. The programme may involve aerobic training such as walking, jogging, running, cycling or rowing and also resistance training. All programmes are designed to place a gradually increasing workload on the body in order to improve fitness. The rate of progression is regulated by exercise, target heart rates and perceived effort of exercise. In signing this consent form I confirm that I have read this form in its entirety and understand the nature of the exercise programme. I also confirm that my questions regarding the exercise programme have been answered to my satisfaction. In the event that medical clearance must be obtained prior to participation, I agree to contact my GP and obtain written permission prior to commencement. I agree to participate in the exercise programme. I assume the risk of exercise and agree to the extent permitted by law, to hold blameless Syz and Fitness Coaches from any claims, suits, losses or related courses of action for damages. Including but not limited to such claims that result from injury or death accidental or otherwise, arising from the exercise programme.

I consent

Please tick to give your consent*