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DEMO STUDIO
DEMO STUDIO
DEMO Pre-Exercise Screening Form
Please take a few minutes to answer the following questions so that we can ensure your success with us.
Name
Date of Birth
Sex
Male
Female
Mobile
Email Address
Occupation
Emergency Contact Name
Emergency Contact Phone Number
Medical Considerations (Part I)
Has a family member (under 60), suffered from heart disease, stroke, raised cholesterol or sudden death
Are you a male over 35 or over 45 and NOT used to regular vigorous exercise?
Are you on any prescribed medication?
Have you been hospitalised recently?
Are you pregnant?
Have you given birth in the last 6 weeks?
Do you have any infections or infectious diseases?
Medical Considerations (Part II)
Gout
Stroke
Diabetes
Epilepsy
Hernia
Asthma
Glandular Fever
Rheumatic Fever
Dizziness or Fainting
Stomach/Duodenal Ulcer
Liver or Kidney Condition
Arthritis
Any Heart Condition
Heart Murmur
High Blood Pressure (over 140/90)
Palpitations or Pains in Chest
Raised Cholesterol/Trigycerides
Muscular Pain
Do you have any Pain or Major Injuries in the following areas:
Neck
Knees
Back
Ankles
If you ticked any of the above please provide more details below.
Medical Acceptance
I warrant that I am physically and mentally well enough to proceed with Body Fit Training sessions. Clients self-clearance of the above conditions.
Are you currently exercising regularly?
Yes
No
If yes, please give details:
Frequency of exercise (times per week):
1
2 - 3
3 - 4
5+
Do you smoke?
Yes
No
If yes, how many per day?
1 - 5
6 - 10
10+
Are you allergic to anything?
What are your goals?
To reduce body fat
To improve aerobic capacity (heart / lung fitness)
To gain some muscle definition
To gain overall fitness
To generally tone up
To gain strength
Marketing Acceptance
I agree to allow Body Fit to use pictures, videos or the like for potential marketing material
Statement
I recognise that the instructor is not able to provide me with medical advice with regards to my fitness, and that this information is used as a guideline to the limitations of my ability to exercise. I have answered questions to the best of my ability and understand the advice above.
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