Questionnaire

Name**

Address*

Mobile No*

Email*

Date of Birth*

Occupation**

Do you have any Medical conditions? If yes please list below.

Have you ever had major surgery? If yes please list below.

Have you ever broken a bone? If yes please list below.

Do you suffer with any digestive issues?

If yes please state, eg. bloating/burping/flatulence/constipation/diarrhoea

Do you sleep well at night?

How many hours sleep do you average per night??

What age did Menopause start??

Are you vegetarian/vegan or follow any special diet??

Brain Health: • Any hereditary relations to Dementia/Alzheimer’s? • Brain fog? • Do you have memory loss? • Do you forget easily??

Send on a report of your last 1, 2 or 3 DXA’s via email or photo on What’s App. You can get these from your GP’s secretary

Send on any recent blood tests results you may have

Send on any recent MRI reports you may have and any rehabilitation exercises you may have

Please list any medications you are currently taking:

Please list any supplements you are currently taking, including brand name:

Please list exercise activities below:

Any exercise program you follow, please list here or attach

Would you say you are at: Beginner/Intermediate/Advanced level regarding exercise?

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