Pre-Exercise Screening Form

Pre-Exercise Screening

Please fill out the following questions prior to attending.
Name*

First NameLast Name
Birth Date*

DayMonthYear
Gender*
Address*

Street Address

Street Address Line 2

CityState

Post Code
Phone*
E-mail*
example@example.com
Emergency Contact Name*
Emergency Contact Phone*
Medical Considerations

It is our professional duty of care to ask all participants no matter age or sex to complete the following questions.
YESNO
YESNO
YESNO
YESNO
GoutStrokeDiabetesEpilepsyHerniaAsthmaGlandular FeverRheumatic FeverDizziness or FaintingStomach UlcerLiver or Kidney ConditionArthritisHeart ConditionHeart MumurHigh Blood Pressure
Do you have any Pain or Major Injuries in your Neck,Knees,Back or Ankles? If Yes, Please list below.
I warrant that i am physically and mentally well enough to proceed with F45 Training Annandale*

Clear
Lifestyle and Current Exercise Habits
YESNO
If Yes, how many days per week?
YESNO
YESNO
If Yes, please list.
Marketing
I agree to allow F45 Annandale to use pictures, videos or the like for social media and marketing.

Clear
I recognise that the instructor is not able to provide me with medical advice with regards to my fitness, and that this information is used as a guideline to the limitations of my ability to exercise. I have answered all the above questions to the best of my ability and understand the advice above. *

Clear
Should be Empty:

Pre-Exercise Screening