Health questionnaire

You are required to complete the following form before you can begin implementing changes to your diet or activity levels. All information will be treated with the strictest confidence.

Name *
Many scales give you this information, but leave blank if yours do not.
Many scales give you this information but leave blank if yours do not.
If unknown, don't worry, I will work this out
Do you suffer from any of the following? Please select yes or no.
Heart disease or another heart condition *
Raised blood pressure *
Raised cholesterol levels *
Diabetes, type 1 or 2 *
Gastrointestinal problems *
Food allergies or intolerances *
Joint problems *
Chest pain or dizziness when exercising *
Any other medical condition not listed *
Are you currently pregnant or breastfeeding?
Are you currently taking medication of any sort? *
Do you smoke? *