• ADULT PRE-EXERCISE

    ADULT PRE-EXERCISE

  • Date of Birth: *
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  • Gender*
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  • STAGE 1 (COMPULSORY)

  • 1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?*
  • 2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?*
  • 3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?*
  • 4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*
  • 5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?*
  • 6. Do you have any other conditions that may require special consideration for you to exercise?*

  • IF YOU ANSWERED ‘YES’ to any of the 6 questions, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise.

    F YOU ANSWERED ‘NO’ to all of the 6 questions, please proceed to question 7 and calculate your typical weighted physical activity/ exercise per week.

  • Please select the session you would like to attend:

  • I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct.

  • Release of Liabilty

    I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct.

    I understand the risks of participating in this program of physical exercises and various use of conditioning and exercise equipment.

    I hereby state that I am in good physical condition and do not suffer from any medical conditions or physical restrains that would prevent me from participating in such physical activity. I fullly understand that I may suffer injury as a result of my participation.

    I hereby release the trainer from any and all liability now or in the future included but not limited to medical expenses, lost wage, pain and suffering that may occure by reason of hyperthermia, heart attacks, muscle strains, pulls or tears, broken bones, splints, foot/ knee/ lower back injuries, and any other soreness, illness or injury, however cause, wheter occuring durin or after participation in the program or use of equipment regardless of fault

    By signing below I attest, acknowledge and agree that I am legally bount and consent.

  • Date*
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  • Should be Empty: