Pre Exercise Questionnaire

Your name*
Date*
DD slash MM slash YYYY
Best contact number*
Gender*
Date of birth*
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Emergency contact*
Please include contact number
Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?*
- Yes
- No
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?*
- Yes
- No
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?*
- Yes
- No
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*
- Yes
- No
If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
- Yes
- No
Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?*
- Yes
- No
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? Please identify all.*
I hereby agree that Outer Strength Fitness, it’s owners and any nominated employees shall not be liable for any loss, damage or personal injury suffered by me, whether directly or indirectly arising out of any act or omission by Outer Strength Fitness, it’s owners or employees. I am aware of the possible health and safety risks associated with participating in physical exercise and consent to any reasonable exercise which may be from time to time strenuous. I have made Outer Strength Fitness, its owners and employees aware of any relevant medical or health problems that I am currently or likely to suffer from and have obtained clearance from a registered medical practitioner to participate in physical exercise. I consent that Outer Strength Fitness have the right to refuse training and refer me to a medical professional, if they deem It is unsafe to exercise. I acknowledge sole responsibility for any personal equipment. I consent to receive medical treatment, which may be deemed necessary in the event of injury, accident or illness. (signed consent of a legal guardian must be obtained if you are under 18 years of age). This information is for the sole use of Outer Strength Fitness and will not be provided to any other source for any use other than that of Outer Strength Fitness training services. Outer Strength Fitness is bound by the National Privacy Principles as set out in the Privacy Act 1988.
Signature*
Please sign with your full name

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