Pre Activity Questionnaire

PERSONAL DETAILS:

Title:*

Firstname:*

Surname:*

Date of Birth:

Postcode only:*

Email:

Mobile/telephone:

Emergency full name:

Emergency number:

MEDICAL CONDITIONS:

Which of the following conditions do you experience?:

Please give details of duration and medications for all conditions::

Have you consulted your physician about increasing your physical activity and/or participating in a physical exercise programme?:

No
N/a
Yes

Has your physician approved you increasing your physical activity level and/or participation in physical exercise programme?:

No
N/a
Yes

INFORMED CONSENT:

The exercise programme is designed to place a gradually increasing workload on the cardiovascular & muscular systems, thereby improve their function.:

The reaction of the cardiovascular and muscular systems to such exercise cannot always be predicted with complete accuracy.:

I acknowledge that there are inherent risks of certain changes that might occur in participating in any programme of strenuous exercise, such as: *:

changes in blood pressure or heart
muscular discomfort during and after the session

I, as the client, am responsible for informing the Trainer of any conditions or changes in my health, which might affect my ability to exercise safely:

I, as the client, accepts full responsibility to: *:

request clarity for any uncertain instruction,
monitor my own condition throughout the exercises,
cease participation if any unusual symptoms occur,
inform the trainer if any unusual symptoms occur.
make payment prior to starting the session

By clicking below, I agree that the answers above are true and complete to the best of my knowledge, and I agree to abide by these terms & conditions.:

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