Your Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What are your main reasons for starting a fitness programme?

Please select all that apply

General Conditioning

Muscular Strength

No time

Weight/Fat Loss

Aerobic Fitness

Appearance

Stress Management

Flexibility

Improve Self-Esteem

Other

Have you ever done structured exercise? *

Yes

No

Medical History: Any major illness injury or operation in the last 5 years? *

Yes

No

Are you receiving treatment for any diagnosed medical condition? *

Yes

No

Are you taking any prescription medication? *

Yes

No

Have you been diagnosed or treated for any of the following?

Please tick all that apply

Anaemia

Asthma

Arthritis

Back Pain

Bronchitis

Diabetes

Depression

Epilepsy

Obesity

Stroke

Other

Please indicate if you every experience any of the following symptoms. Do you:

Ever get unusually short of breath with very light exertion?

Ever have pain, pressure, heaviness or tightness in the chest area?

Regularly have unexplained pain in the abdomen, shoulders or arm?

Please indicate if you ever experience any of the following symptoms. Do you:

Ever have severe dizzy spells or episodes of fainting?

Regularly get lower leg pain during walking that is relieved by rest?

Ever experience palpitations or irregular heartbeats?

Are you currently pregnant or have you given birth in the last 6 months? *

Yes

No

I can confirm that I have answered all questions honestly and that the information given is correct. I willingly participate in the practical exercises at my own risk. I have no physical restrictions, disabilities or any predisposition to sickness or injury that may be aggravated or adversely affected as a result of my participation. I take full responsibility for any injury, loss or damage to my person or property that may arise from my participation in the exercises - be it in class, Zoom classes online, or following YouTube content. I will not seek to penalise, prosecute, or claim compensation from the company for any injury, loss or damage. *

I confirm

Name *

First Name

Last Name

Date *

MM

DD

YYYY