Medical and Health Details

Name*

First NameLast Name

Age:

Date of Birth:*

Date

Email address:*

example@example.com

Mobile Phone Number (inc country code)*

Country CodeArea CodePhone Number

Phone Number (inc country code)

Country CodeArea CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Number of Children and age

Marital Status

SingleLive with a friend or partnerMarriedDivorced/ Widow

Name of next of kin*

First NameLast Name

Next of Kin email*

example@example.com

Next of Kin Phone Number (inc country code)*

Please enter a valid phone number.

Do you smoke?

YesNo

What time do you get up and what time do you generally go to bed?

How well do you sleep - how many hours roughly?

On an average day what would you eat for Breakfast and when?

On an average day what would you eat for lunch and when?

On an average day what would you eat for dinner?

Fluid intake - please specify how much caffeine/ water/ soft drinks/ sodas you drink per day and how much alcohol you drink per day and or days per week. *

How many days a week would you get your heart rate up to puffing

1-2 days3-4 days5-6 dayseveryday

Are you familiar with and do you do any core stabilising work?

Please outline your current weekly exercise regime if you have one

Medical Details

Have you come in contact with anyone with Covid 19 Virus in the last 1 month*

YesNoUnsure have been mixing with unkown others

Have you been vaccinated against Covid 19.

Yes - I have had 1 vaccinationYes - I have had 2 vaccinationsNo - I have had no vaccinations

Are you currently taking any other medication? If so please elaborate.*

Are you allergic to any medication?*

Are you allergic to anything else? Food/ Fabric/ Substances?

Are you currently or have you in the last few years experienced any discomfort or pain - if so where?*

Have you ever had any breaks or strains? If so how and when?*

Have you ever had any operations? If so please give details.*

Have you received any other treatment recently - physio/ chiropractics/ Osteo?

Have you ever had any road traffic accidents? If so where you affected?*

Doctors Name*

First NameLast Name

Doctors telephone number*

Please enter a valid phone number.

Medical History - have you or your parents suffered from any of the following?*

	You Yes	You No	Parent Yes	Parent No
Liver/ Kidney
Heart/ Stroke
Lung/ Breathing
Digestive
Bowel/ Bladder
Reproductive System
Circulation Problem
Diabetes
Cancer
Epilepsy/ Nervous disorder
Allergy/ Skin
Blood Pressure issues
MIgraine/ Headaches
Dizziness
Tinnitus (buzzing in ears)
Eyes, Ears, nose, throat issues
Arthritis/ Orthopaedic issues
Multiple Sclerosis
Recently gained or loos weight

Please give more detail if you answered yes to any of the above or if there is anything else that we should know about?

I declare that the above is true to the best of knowledge. I understand that exercise can be physically demanding, and as a condition of my enrolment, I accept full responsibility for my participation. This means I acknowledge the recommendations from Emma of Biospheric Performance, and I will obtain a Doctors health check before commencing exercises should it be considered necessary. I appreciate that I may be undertaking exercise over live video conferencing and that there may not be hands-on interaction. I also acknowldeg that I may be given videos or exercise sheets that I will need to do in my own time in order to get to the deisred end goal. I declare that I am fit and healthy to participate and appreciate that good communication/ listening (on both sides) and interpreting is key to success.

Having agreed on an appointment for Personal Training/Biomechanics Coaching, an entry goes into the trainer's diary which is binding. Your trainer will be designing you a program - so failure to turn up will incur a fee unless 36hours notice is given and the appointment re-scheduled and made up for in that week. Blocks of 10 sessions have no refund and are to be used within a 10 month time period.

You are entering into a contract with yourself for your fitness and with your trainer for their time, there is, therefore, an obligation to this financial commitment. All sessions will be paid for upfront. Exceptional unforeseen circumstances will be aaccepted at teh discretion of the trainer, but due to a new policy, all cancellation without re-scheduling and 36hours notice will be charged for. If we do fill your vacant slot however we will not charge you, but this is not usually possible at short notice.

Please read the Terms and Conditions - signing below is a statement that you acknowledge you understand these T&C’s.

Thank you for understanding and welcome to getting in shape!

Signature

Medical and Health Details

Personal Details

Lifestyle

Nutrition

Current Exercise

Declaration: