Clinical screening form

Before you can commence training I need to know the following: (Please fill in all fields)

Your name(Required)

Email(Required)

Emergency contact name(Required)

Emergency contact number(Required)

What are you fitness goals and expectations, please provide details here:(Required)

History of heart problems, if yes please provide details here:(Required)

Has your doctor ever said your blood pressure is too high, if yes please provide details here:(Required)

History of muscle or joints problems, if yes provide details here:(Required)

History of breathing or lungs problem, if yes please provide details here:(Required)

Taking prescribed medication? If yes, please provide detail here:(Required)

History of chest pains that move down the arm at rest or when exercising, if yes provide details here:(Required)

History of unexplained fatigue/tiredness, if yes please provide details here:(Required)

History of dizziness / falls / vertigo / vision or hearing changes, if yes please provide details here:(Required)

History of seizure and/or unexplained loss of consciousness, if yes please provide details(Required)

Recent birth / miscarriage / pregnancy, if yes please provide details here:(Required)

Recent surgery, if yes please provide details here:(Required)

History of excessive muscle cramps, if yes please provide details here:(Required)

Do you suffer from anaphylaxis? If yes please provide details here:(Required)

History of muscle/joint pain and/or swelling preventing you from exercising, if yes please provide details here :(Required)

Do you have hernia or any condition that can be aggravated by lifting weights, if yes please provide details here:(Required)

Do you know any other reason why you should not do any physical activity, if yes please provide details here:(Required)

Phone

This field is for validation purposes and should be left unchanged.