Pre-Exercise Screening Form

Pre-Exercise Screening Form

Studio Sessions, Private & Semi-Private Sessions
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
DOB*

DayMonthYear
Date
Occupation*
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
Please enter a valid phone number.
Current Injuries*
Injuries that you are currently aiding.
Previous Injuries*
Injuries that you are no longer suffering from.
Restrictions*
e.g - unable to lift arm above 90 degrees due to injury
Medical Conditions*
Medications*
Treatments*
E.g - Osteopathy once a fortnight.
Have you ever had any undiagnosed pain in any of the following areas? Please select all that apply.*

NeckShouldersBackHipsKneesAnklesOther
Please give details of the above including how they have affected your everyday life:*
Are you pregnant?*

YesNo
Has your medical practitioner ever told you that you have a heart condition, or have you ever suffered a stroke?*

YesNo
Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?*

YesNo
Do you ever feel faint, dizzy, or lose balance during physical activity/exercise?*

YesNo
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*

YesNo
If you have diabetes (type 1 or 2), have you had any trouble controlling your blood sugar in the last 3 months?*

YesNo
Do you have any other conditions that may require special consideration for you to exercise?*

YesNo
Current Exercise*
Usual Intensity*
Frequency*
Do you have any concerns about physical activity?*
Client Goals*
How did you hear about us?*
I agree that the information I have given on this document is true and correct. I have read and understood all the wording printed on this document. I take full responsibility for my actions at any and all times on site, off site and on-line. This includes during any workouts, classes, practice and use of equipment whilst engaged in activities at Alive Yoga & Pilates.
Client Signature*

Clear
Should be Empty: