Exercise Screening Form

Exercise Screening Form

All information will be kept private and confidential
Full Name *

First Name Last Name
Email *
example@example.com
Date of birth

Day Month Year
Date
Phone Number *

Area Code Phone Number
Emergency contact *

First Name Last Name
Emergency contact phone number *

Area Code Phone Number
How did you hear about the class?
Which class/classes are you interested in?
Are you currently exercising?

Yes No
If yes, please describe activity, duration, intensity
What are your goals for participating in exercise?
Have you experienced any of the following in the past or present:

Asthma Arthritis Cancer Cardiac disease Diabetes Hypertension Psychiatric disorder Epilepsy Bronchitis Pneumonia Thyroid Issues Hernia Migraine/Headaches High blood pressure Low blood pressure Wrist pain-Carpel Tunnel Syndrome Abdominal cramps Pelvis / Pubic pain Prolapse / weak Pelvic Floor Joint problem –neck / back / shoulder / knee / hip / ankle
Check any symptoms that you're currently experiencing:

Chest pain Respiratory Cardiac disease Cardiovascular Hematological Lymphatic Neurological Psychiatric Gastrointestinal Genitourinary Weight gain Weight loss Musculoskeletal
Please give details of any of the above conditions or symptoms, if applicable
Are you currently taking any medication that your instructor should be aware of? *

Yes No
If yes, please give details
Do you have any medication allergies? *

Yes No Not Sure
Do you use or do you have history of using illegal drugs?
How often do you consume alcohol?

Daily Weekly Monthly Occasionally Never
Do you use or do you have history of using tobacco?
Are you PREGNANT or had a baby within the last 6 months? *

Yes No
Is there any reason why you should not participate in physical activity? *

Yes No
Please give any other information you feel is relevant
By sumitting this form, I hereby confirm that all the above information is correct and accurate at the time of activity.

I know of no reason why I should not participate in an exercise programme. I have been cleared by a doctor for physical activity.

I agree to advise in writing if any changes to my health should affect my participation.I take part at my own risk and I waive any legal recourse for damages to myself or property arising from participation
Date

Day Month Year
Date
Signature *

Clear
Should be Empty:

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