Omni Health, Medical and Goals Questionnaire

About This Questionnaire

I understand the purpose of this programme is to provide safe and individualised exercise sessions to improve health and fitness. The programme may include:

• Cardiovascular activity: walking, jogging, running, use of equipment, high-intensity interval    training, team sports, circuit training and other such activities
• Resistance/Strength training: bodyweight exercises, use of equipment
• Warm up, cool down and flexibility exercises

Potential risks:

This programme is designed to place a gradually increasing workload on the cardiovascular and muscular systems to improve their functions. There is a risk of certain changes that may occur during or following the exercise which could affect blood pressure or heart rate and the possibility of muscle soreness.

Potential benefits:

Regular exercise and an improved diet have a positive impact on the body. Benefits include:

•A decreased risk of heart disease
•A decrease in body fat
•Improved blood pressure
•Improved physiological function
•Improved fitness

The programme has been explained to me and my questions regarding the programme have been answered to my satisfaction. I understand that I can withdraw at any time. This information is treated as private and confidential.

MEDICAL QUESTIONNAIRE

This is designed to help us to develop a programme that is suited to your health needs. For most people, increasing the amount of physical activity or making changes to your diet will not pose a problem or hazard, however, this will allow us to minimise risk and if necessary allow you to seek medical advice before proceeding.

Please be honest when answering the following questions. Your answers are treated as private and confidential.

If you are between the ages of 16 and 69, the below questions will provide guidance on programming and exercise types. If you are above 69 and aren’t currently very active, please check with your GP before commencing any type of physical activity.
First Name *
Last Name *
Phone Number (For Whatsapp Check-ins) *
Emergency Contact Phone Number *
Date Of Birth *
Age *
What Is Your Occupation *
Phone Number (For Whatsapp) *
Current Weight (kg) *
On average, how much sleep do you get every night? *
Has your doctor ever said that you have a heart condition and that you should only undertake physical activity recommended by a doctor? *
Do you feel pain in your chest when you undertake physical activity? *
In the past month, have you had chest pain when you were not doing physical activity? *
Do you often feel faint, have spells of severe dizziness or loss of consciousness? *
Have you ever suffered from unusual shortness of breath at rest or with mild exertion? *
Do you have Either high or low blood pressure?
Do you have any chronic illness or physical limitations such as asthma or diabetes? *
Have you had Covid-19 in the past 12 months? *
Are you on any prescribed medication? *
Do you have a bone, joint or muscular condition (for example, arthritis) that could be made worse by a change in physical activity? *
Are you currently pregnant or have you had a baby within the last 24 months? *
Do you know of any other reason that would affect your ability to take part in physical activity? *
If you answered yes to any of the previous questions, please provide detail here. If recently been pregnant, please let us know and we will send you a specific questionnaire.
What are your long-term goal/s (12 months) in relation to your health and wellbeing? *
What are your short-term goals (8 weeks) in relation to your health and wellbeing? * *
Do you have any fitness equipment at home? If yes, please list what you have including weights/number of pieces etc? *
Describe your current fitness regime, if any. Think about the frequency of sessions, intensity and type. Are you a member of a gym? Have an active hobby etc?
Do you currently use the MyFitnessPal app? *
Do you give consent for photographs/videos to be taken during sessions and used by Omni for social media and marketing? *
Are you willing to keep an honest food diary for a minimum of 5 days? *
Would you like some nutritional support? *
Would you like programming for home or gym? *