Health Questionnaire
Name:
Address:
Postcode:
Phone Nos:
Email:
Age/DOB:
Occupation:
How did you find Cardiostriptease.co.uk? If not listed please state how here
Medical Questionnaire
1. Anyone in your family with heart disease, high blood pressure stroke, raised cholesterol levels?
2. Are you a male over 35 or female over 45 and not used to regular exercise?
3. Are you on any prescribed medication (eg HRT)?
4. Have you given birth within the last 6 weeks?
5. Do you have weak pelvic floor muscles?
6. Do you smoke?
7. Are you dieting or fasting?
Do you have or have you had? please tick all that apply
Gout	Glandular Fever
Stroke	Rheumatic Fever
Diabetes	Dizziness or fainting
Epilepsy	Stomach or Duodenal Ulcer
Hernia	Liver or Kidney problems
Special training considerations body overview - Have you ever had or do you have any pain or major injuries particularly the following areas?
Arthritis	Neck	Back
Asthma	Knees	Ankles
Cramps	Shoulders	Muscular Pain
Other
If you answered positively to any of the above - please can you give me as much information as possible below:

Terms & conditions

Tel 01622 763965			© Cardiostriptease Limited 2007. All rights reserved.

Thank you for your booking - please complete the following health and medical questionnaire.

Tel 01622 763965