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Name: Phone: Mobile:   Sex: Select One Male Female D.O.B E-mail Address: Suburb: City: Occupation:     How Did You Hear About Us: Sighted Location: Flyer: News Paper: Radio: Internet Ad: Internet Search: Referral By:

Have You Joined A Fitness Club Before:	Select One Yes No
If Yes Is Membership Current:	Select One Yes No
Are You Presently Exercising	Select One Yes No
If Yes What Type:
How Many Times A Week:

What Results Do You Want To Achieve?

Weight Loss: Sports Fitness: Nutrition: Rehabilition: Weight Gain: Toning: Personal Training: Personal Development:

The following information is required to assist us in developing a safe exercise programme for you. The collection use and storage of this information, will comply with the obligations of the privacy act 1993 and the Health Information Privacy Code 1994.

Please Answer The Following:
Are you on Prescribed Medication?	Select One Yes No
Are you pregnant or have you given birth within the last 12 weeks?	Select One Yes No
Have you had any recent surgery?	Select One Yes No
Have you had major injuries?	Select One Yes No
Do you or have you ever had:
Diabetes?	Select One Yes No
Heart Condition / High or low blood pressure / Chest pain?	Select One Yes No
Asthma or breathing disorder?	Select One Yes No
Epilepsy?	Select One Yes No
Stroke?	Select One Yes No
Dizziness or Fainting?	Select One Yes No
Arthritis?	Select One Yes No

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It is recommened that all Males over 35 and Females over 40 gain medical clearance before undergoing any fitness programme.

 

 

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