First Name
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Last Name
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Pronouns
Phone Number
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Email
*
example@example.com
Birthday
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Day
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Month
Year
Emergency Contact Number
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Emergency Contact Name
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How did you hear about Darkside Movement?
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Internet
Social Media
Word of Mouth
A Darksider
If you said Darksider, what is their name?
We have a referral program and would love to offer them something special!
Please read the following questions carefully and check YES/NO. Answer all questions honestly and to the best of your ability. If you answer yes to any of the questions we will require a medical clearance from your General Practitioner prior to commencement of exercise.
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YES
NO
Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or that you should only do physical activity recommended by a doctor?
lity
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
Do you have a diagnosed illness that could be made worse by physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Are you currently pregnant?
Have you given birth in the last 12 months?
If yes to above question, have you been seen by a Womens Health Physio?
If you are currently pregnant or have given birth in the last 12 months could you please provide us with the appropriate information:
If pregnant, how many weeks?
If postpartum, what kind of birth did you have?
Child's Date of Birth:
Please list any injuries, medical concerns or other information you would like our trainers to be aware of:
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