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Name (required)

Email (required)

Address

Phone Number

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Emergency Contact Person
Name

Phone Number

Email

How would you describe your current physical condition?
UnwellOverweightUnfitHealthyFit

What regular exercise do you currently do?

Have you ever had OR do you have?
Stroke:YesNo
Heart Condition:YesNo
Diabetes:YesNo
Epilepsy:YesNo
Heart murmur YesNo
Dizziness:YesNo
Fainting:YesNo
Palpitations or pain in the chest:YesNo
High blood pressure <140/90:YesNo
Low blood pressure:YesNo

Are you, OR have you recently had or done any of the following?
Prescribed medication:YesNo

Are you pregnant:YesNo
Given birth in the last 6 weeks:YesNo
Have you been hospitalised recently?:YesNo
Dieting or fasting?:YesNo

**Please Note: If you have circled YES to any of the above OR you are NOT SURE – We will recommend
that you see a doctor prior to beginning an exercise program

Have you ever had or do you have?
Arthritis:YesNo
Cramps:YesNo
Asthma:YesNo
Muscular Pain:YesNo
Did you, OR do you smoke?YesNo

Do you experience any pain OR major injuries particularly in the following areas?
Neck:YesNo
Knees:YesNo
Back:YesNo
Ankles:YesNo
Have you had any major surgery?
YesNo

Are there any other conditions not mentioned which may be a reason to modify your exercise
program?

MUMS AND BUBS – BABY AND MEDICAL INFO
Are you bringing any kids: YesNo

I have read and understood the Terms and Conditions and know that it affects my legal rights.

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