FitClub Health & Fitness Screening Form

Adult Pre-Exercise Screening Form
For FitClub participants
Full name*
First NameLast Name
Birth Date*
DayMonthYear
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
E-mail*
Your Mobile Number:*
Area CodePhone Number
Emergency contact*
First NameLast Name
Their relationship to you:
Emergency contacts Mobile Phone number*
Area CodePhone Number
Health questionnaire - Fitness Australia

Please answer every question:*

	Yes	No
Has your doctor ever said that you have a heart condition or have you ever suffered a stroke?
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
Have you had an asthma attack requiring immediate medical attention at any time over the past 12 months?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
If you have diabetes (type 1 or 2) have you had any trouble controlling your blood sugar level in the past 3 months?
Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise?

If you answered YES to any of the above - please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise.
If you answered NO to all of the above questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise.
Any other info I should know in order to help you exercise safely?
I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Initials*
Clear
Liability waiver
I am aware of the risks in observing or participating in the activities offered at FitClub and I understand that all sports or fitness that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realize that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me, damage to my property, or damage arising out of my death. It is understood that FitClub is responsible for any damage that would be resulting from a fault of FitClub and its representatives.
Initials*
Clear
We want you to get the best out of FitClub!
Please answer the questions below!
I joined FitClub because I want to: (tick all that apply)
get fitterlose weighttone upto help with other sports i doget healthiermeet peopleOther
The things that are important to me from FitClub are: (please tick all that apply)
I have funI meet nice peopleI see results (eg: fitness, weightloss, health etc)Good variety of workoutsNot too difficultI like a challenging workoutOther
Signature
Signature*
Clear
Thank You!
This will save time at your first session! I look forward to seeing you at FitClub and working with you to help you get in the best shape of your life! Julie Chalmers (Health & Fitness Coach) 0404 338610
Should be Empty:

Adult Pre-Exercise Screening Form

Health questionnaire - Fitness Australia

Liability waiver

We want you to get the best out of FitClub!

Signature

Thank You!