Intake form

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Intake Form Chiswick Studio

07305 011863

info@emsfitchiswick.co.uk

Please answer the following:

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Name *

Date of Birth *

Mobile *

E-mail *

Your goals:

How did you find out about EMS FIT London? *

What attracted you to find out about EMS FIT London? *

Do you have any specific goals you want to achieve? In what time frame? *

What exercise, sport or physical activity do you currently do? *

Please also answer these questions below:

Have you been fitted with implanted electronic devices such as pacemakers, implanted defibrillators, neuro-stimulators or pain pumps? *

Do you have, or have you had any heart problems, chest pains or strokes? *

Do you have any blood pressure problems? *

Do you or have you had any chronic illness or ailment in the last 3 months? *

Do you experience pain or difficulty during physical exertion? *

Do you regularly suffer from headaches or migraines? *

Have you had any surgery in the last 3 months? *

Are you pregnant or have you been pregnant in the last 3 months? *

Do you have lung or breathing problems? *

Do you have any injuries to your muscles, joints or back, or are you still suffering from past injuries? Any back problems such as herniated disc? *

Do you have diabetes? If so, what type? *

Do you have a thyroid deficiency? *

you should from

Do you have weight problems? *

Do you have any allergies? *

Are you undergoing medical treatment or do you take medicines? *

Height (in centimeters) *

Weight (in kilograms) *

Is there anything else we should know about? *

Comments:

Please advise us if any changes occur.

EMS FIT London advice & data privacy
We will guide you with care and respect. You acknowledge responsibility for risks that exist in all types of training, sport or exercise. If you have any physical complaints you are unsure about, please consult your doctor before starting any exercise programme. You acknowledge responsibility for any consequences that arise from inaccurate information given on this form. Your personal information is handled in full confidence. We never pass your details to third parties.

Declaration. I agree to the above advice and data privacy policy: *

Date when filled out *