The UQ HMNS Personal Trainer Service will be offered in Semester 1 and Semester 2 in 2019. Please complete all relevant information below and select the package of your choice. 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 3 preferences.

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* 8. Time preference on your 1st choice.

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* 9. Additional comments regarding your time preferences.

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* 10. Please select your preferred package option.

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* 11. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?

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

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* 13. Do you ever feel faint or have spells of dizziness during physical
activity/exercise that causes you to lose balance?

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

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* 15. If you have diabetes (type I or type II) have you had trouble
controlling your blood glucose in the last 3 months?

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

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* 17. Do you have any other medical condition(s) that may make it
dangerous for you to participate in physical activity/exercise?

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* 18. 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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* 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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