Health Screen Form

Full Name*

First NameLast Name

Best Contact Number*

Mobile

E-mail*

Address

Street Address

Street Address Line 2

CityState / Province

Post CodeCountry

Emergency Contact Person*

Area CodePhone Number

Date of Birth*

MonthDayYear

Are you active on a daily basis?*

YesNo

What do you do for a living?

How would you rate your current physical fitness?

	1	2	3	4	5	6	7	8	9	10

1 is Poor, 10 is Athlete

Were you referred to us by one of our clients?*

YesNo

If YES, please help us reward them:

First NameLast Name

Are you pregnant?*

N/AYesNo

If yes, do you have a medical clearance to exercise?

YesNo

Have you had a baby in the last 6 weeks - 6 months? If yes do you have a medical clearance to exercise?

YesNo

Have you ever suffered from...?

Have any of your first degree relatives experienced the following conditions?

Have you had surgery in the last two years?

YesNo

If YES, Details...

Do you suffer from back pain?

YesNo

If YES, Details...

Do you have any injuries?

YesNo

If YES, please list...

Do you smoke?

YesNo

1.) CANCELLATIONS Cancellations should be made at least 12 hours in advance of a scheduled session. Sessions cancelled less than 12 hours in advance will be charged in full to the client.

2.) LATE ARRIVALS Each session will be 45min in length. Sessions will not be extended due to lateness or interruptions caused by the client.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT All the information on this form is correct and to the best of my knowledge. If I have answered YES to any of the above questions I will seek and follow any medical advice. I understand that all the information given will be kept confidential.

4.) I'm physically capable and there are no medical conditions to prevent me from proceeding with exercising with Stefitness. I acknowldge that I will not hold Stefitness accounatble for injury, damage or loss of property.

I AGREE to the above terms and conditions.*

YesNo

Signature

Contact Details

Pre & Post Natal

Medical History

Please Read The Following T&C's.