Please fill in your Pre-test Journal before your appointment
Full Name
*
Email
*
Phone
Date of birth
Gender:
Male
Female
Height in inches:
Weight (in lbs):
Scheduled for a DEXA scan?
Yes
No
Ethnicity
Chance of pregnancy?
Yes
No
Weigh over 350 lbs?
Yes
No
Recent gastrointestinal contrast/radionuclides?
Yes
No
Condition preventing lying still for 6 mins?
Yes
No
Diagnosed with Type 2 Diabetes?
Yes
No
Diabetes diagnosis date
Diagnosed with Cancer?
Yes
No
Cancer Type
Cancer diagnosis date
Diagnosed with Heart Disease/CVD?
Yes
No
CVD Type
CVD diagnosis date
Scheduled for VO2max test?
Yes
No
Doctor said you have a heart condition?
Yes
No
Lose balance/dizziness/consciousness?
Yes
No
Chest pain during physical activity?
Yes
No
Taking heart/blood pressure prescription?
Yes
No
Bone or joint problem made worse by activity?
Yes
No
Consent to data processing
I consent