Pre Exercise Questionnaire

Pre Exercise Questionnaire
FULL NAME
DOB

DayMonthYear
PHONE NUMBER
EMAIL
EMERGENCY NAME & NUMBER
ADDRESS

Street Address Line 2

CityState / Province

Postal / Zip Code
OCCUPATION
WHERE DID U HEAR ABOUT BOWENFIT?
Are you currently exercising?
Frequency & description of exercise
What results are you wanting to achieve?
What class day/time suits you?*

Mon 9.15amMon 5.15pmFri 9.15am
MEDICAL HISTORY - Please mark 'X' Do you or have you had any of the following:

Shoulder PainCoccyx InjuryBack PainNeck PainMuscle InjuriesIncontinenceHigh/Low BPWeight IssuesHormonal IssuesAllergiesDepressionCardiovascular IssuesImplantsDiabetesCancerAsthmaRespiratory IssuesBlood disorderHigh CholesterolArthritisHerniaOsteoporosisStressMSLymphatic IssuesFibryomyalagia or MERecent SurgerySmokerThyroid issuesOther
Details (if yes to any of the above)
Do you have any injuries that may effect your training?
Are you currently taking any prescribed or over the counter medication?

YesNo
List medication:
Details of any special diet:
Low carb, fasting, meal plans, low calorie, etc.
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
I agree the above information provided is correct and I have addressed all of my medical conditions and restrictions that may lead to injury, limit or restrict my training. I understand that I take FULL responsibility for my voluntary participation in any fitness classes and activity offered by BOWENFIT. I do NOT hold BOWENFIT and or any trainer associated with BOWENFIT or the City of Stirling accountable for any injury or loss that may be caused during or after any fitness training session/s.
At times photos may be taken during class times and I may be asked if promotional photos can be added to BOWENFIT website, Facebook or Instagram pages for advertising purposes only.
DATE

DayMonthYear
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