EFTA02677388

Medical History Questionnaire Trial Session First Name: Middle Name: Last Name: Gender MI F Birthday: _I _l_ Age: Mobile phone: Home phone: Work phone: Email: Adress: City: Country: Emergency Contact Information: Name: Relationship: Phone: Email: How did you heard about us? Contra-Indicators Miha Bodytec 1. Do you suffer from epilepsy? (brain disorder) no yes 2. Do you suffer from acute thrombosis? (heart disease) no yes 3. Do you use a pacemaker? (device used to heart) no_ yes 4. Do you suffer from serious medical conditions like cancer or MS? (Disease attacks the central nervous system) no_ yes 5. Are you pregnant? no yes 6. Dou you suffer from severe circulatory disorders? (Problems to heart, blood vessels) no_ yes 7. Do you suffer from tuberculosis? (bacteria to lungs) no_ yes 8. Do you suffer from severe neurological disorders? (Disorder to brain & spinal cord) no yes 9. Do you suffer from Diabetes mellitus? (high sugar) no_ yes 10. Do you suffer from bleeds? (Hemophilia) no yes 11. Do you suffer from abdominal or inguinal hernia? (Tissue through abnormal opening) no_ yes Do you have any problems with your joints at the moment? no_ yes What is/are your goals/s? On which area you would like to focus on? Place, Date, Signature: Personal Fitness Train•ng Al (lades Town Houses, Al Wasl Road, lumeirah 1 Dubai, U.A.E. [email protected] www.my30minutes.com Seite 1 von 3 EFTA_R1_01972035 EFTA02677388 Cardio circulatory system 1. Do you suffer from stress in your work or private life? No_ yes, what kind of stress? 2. When did you last go to the doctor? Why? Do you know your blood pressure value? no_ yes 3. Do you know your resting heart rate? no_ yes 4. Do you have any kinds of heart problems or cardio circulatory problems? Did you have any in the past? no yes 5. Do you know your cholesterol level? no yes 6. Do you have stomach trouble? Did you have any in the past? no yes 7. Do you suffer from allergies or chronic diseases? no_ yes 8. Are you taking any medication? (Beta blockers, dietary supplement, the Pill) no_ yes 9. Women only: Do you suffer from any menstrual conditions? no_ yes 10. Women only: Do you have natural children? no yes - If yes, what was your pregnancy like? - What was the delivery like? (E.g. C-section) - Are you in menopause? no yes 11. What did you look like as a teenager? (body proportions) Active and passive locomotor system 1. Do you suffer from injuries or did you have any in the past? Did you have to stay in hospital in recent years? No if yes, when and what kind of problems did you have? 2. Do you suffer from whiplash or numbness? Did you do so in the past? (injuries to the neck) No if yes, when and where? 3. Do you have problems with the following joints: Torso: A) Shoulder no yes Elbow no_ yes Hand no yes Finger no yes Trunk: B) Cervical spine no yes Thoracic spine no yes Lumbar spine no_ yes Seite 2 von 3 EFTA_R1_01972036 EFTA02677389 Legs: C) Sacroiliac joint no yes Hip joint no yes Knee joint no yes Talocalcanean joint no yes Foot no yes 4. Do you suffer from rheumatism? no_ yes 5. Do you suffer from osteoarthritis/arthritis? no_ yes 6. Do you suffer from osteoporosis? no yes Aims and training 1. What kinds of sports/private activities did you perform? 2. How many times? 3. How often do you want to train at my30minutes? 4. What are your aims for your my30minutes personal fitness training? Lifestyle 1. Do you smoke? no yes not anymore 2. If yes, how many cigarettes each day? 3. If not anymore, when did you have your last cigarette? 4. Do you drink alcohol? no_ yes 5. If yes, what kind of alcohol and how much per week do you drink? 6. What does your diet look like? 7. Please state the following for at least three days: What does your biorhythm look like? What is your sleep like? 8. What are your hobbies? General informed consent regarding medical history: The information above is necessary to avoid any potential risks for training with Miha Bodytec. In this respect. the customer states his consent with the collection and storage of this data. The collection of data is made solely for the purpose of implementing smooth personal training sessions. The customer certifies that the information given above is true and given in good faith. If there are any risk factors, the customer will present a medical certificate from his family doctor/attending physician prior to the first training session, stating that there are no medical reasons to doubt his taking part in the training with Miha Bodytec. All data is collected and used only for the optimum purposes of the training. Date, Place Name/Signature Seite 3 von 3 EFTA_R1_01972037 EFTA02677390