Exercise Screening Form

Exercise Screening Form

All information will be kept private and confidential
Full Name*

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

DayMonthYear
Date
Phone Number*

Area CodePhone Number
Emergency contact *

First NameLast Name
Emergency contact phone number*

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

YesNo
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:

AsthmaArthritisCancerCardiac diseaseDiabetesHypertensionPsychiatric disorderEpilepsyBronchitisPneumoniaThyroid IssuesHerniaMigraine/HeadachesHigh blood pressureLow blood pressureWrist pain-Carpel Tunnel SyndromeAbdominal crampsPelvis / Pubic painProlapse / weak Pelvic FloorJoint problem –neck / back / shoulder / knee / hip / ankleOther
Check any symptoms that you're currently experiencing:

Chest painRespiratoryCardiac diseaseCardiovascularHematologicalLymphaticNeurologicalPsychiatricGastrointestinalGenitourinaryWeight gainWeight lossMusculoskeletalOther
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?*

YesNo
If yes, please give details
Do you have any medication allergies?*

YesNoNot Sure
Do you use or do you have history of using illegal drugs?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
Do you use or do you have history of using tobacco?
Are you PREGNANT or had a baby within the last 6 months?*

YesNo
Is there any reason why you should not participate in physical activity?*

YesNo
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

DayMonthYear
Date
Signature*

Clear
Should be Empty: