Pre-Exercise Screening Form

Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Mobile(Required)

Email(Required)

Occupation

Emergency Contact Name(Required)

Emergency Contact Mobile(Required)

Please tick options that apply to you(Required)

Has a family member (under 60), suffered from heart disease, stroke, raised cholesterol or sudden death?

Are you a male over 35 and NOT used to regular vigorous exercise?

Are you on any prescribed medication?

Are you pregnant?

Have you given birth in the last 6 weeks?

Do you have any infections or infectious diseases?

None of the above

Please tick conditions that apply to you (Part 1)(Required)

Gout

Stroke

Diabetes

Epilepsy

Hernia

Asthma

None of the above

Please provide more details below

Please tick conditions that apply to you (Part 2)(Required)

Glandular Fever

Rheumatic Fever

Dizziness or Fainting

Stomach/Duodenal Ulcer

Liver or Kidney Condition

Arthritis

None of the above

Please provide more details below

Please tick conditions that apply to you (Part 3)(Required)

Any Heart Condition

Heart Murmur

High Blood Pressure (over 140/90)

Palpitations or Pains in Chest

Raised Cholesterol/Trigycerides

Muscular Pain

None of the above

Please provide more details below

Do you have any pain or major injuries in the following areas?(Required)

Neck

Knees

Back

Ankles

None of the above

Please provide more details below

Medical Acceptance(Required)

I warrant that I am physically and mentally well enough to proceed with F45 Training sessions. Clients self-clearance of the above conditions.

Are you currently exercising regularly?(Required)

Yes

How many times are you exercising per week?(Required)

2 - 3

3 - 4

What type of exercise are you currently doing?(Required)

Do you smoke?(Required)

Yes

How many do you smoke per day?(Required)

1 - 5

6 - 10

11+

Are you allergic to anything?(Required)

Yes

What are you allergic to?(Required)

What are you goals?(Required)

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(Required)

I agree to allow F45 to use pictures, videos or the like for potential marketing material.

Statement(Required)

I recognise that the instructor is not able to provide me with medical advice with regard 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.

WANNEROO

WANNEROO

F45 Wanneroo
PRE-EXERCISE SCREENING FORM

Please take a few minutes to answer the following questions so that we can ensure your success with us.