The UQ HMNS Personal Trainer Service is running again in Semester 2 of 2019. The service will run from July 29th to October 14th, 2019 and is ONLY $100. Please complete all relevant information below. You will be contacted shortly after completion of this survey to notify you of your eligibility and upcoming important dates. Thank you for your time!

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* 1. Full name.

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* 2. Gender.

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* 3. Date of Birth.

Date

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* 4. Best Contact Number.

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* 5. Email Address.

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* 6. Current Physical Activity (e.g. Walking 3 days/wk for 30min).

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* 7. Preferred session time. Please order your top 4 preferences.

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* 8. Additional comments regarding your time preferences.

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* 9. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?

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* 10. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?

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* 11. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?

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* 12. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

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* 13. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?

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* 14. Do you have any other conditions that may require special consideration for you to exercise?

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* 15. If you answered 'Yes' to any of the above questions, could you please provide further details. 

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* 16. Do you have any diagnosed muscle, bone, tendon,
ligament or joint problems that you have been told
could be made worse by participating in exercise?

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* 17. Do you have any immediate family members (i.e. parents/siblings) that have suffered a heart attack or stroke? If no, please type no. If yes, please detail your relation to the person and the age they were diagnosed (e.g. father, age 60).

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* 18. Do you smoke cigarettes on a daily or weekly basis or
have you quit smoking in the last 6 months? If no, please type no. If yes, please specify how many per week.

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* 19. Have you ever been told you have high blood pressure?

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* 20. Have you ever been told that you have high cholesterol?

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* 21. Have you ever been told you have high blood sugar?

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* 22. Have you recently been injured, require rehabilitation exercises or seeking a sport specific program to aid in current sport specific training? If no, please type no. If yes, please provide details. 

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* 23. Have you spent time in hospital (including day admissions) for any medical condition/illness/injury during the last 12 months? If no, please type no. If yes, please provide details.

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* 24. Are you currently taking a prescribed medication(s) for any medical condition(s)? If no, please type no. If yes, please provide details. 

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* 25. Are you pregnant or have given birth within the last 12 months? If no, please type no. If yes, please provide details.

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