Pre-Exercise Questionnaire
Thank you for completing the questionnaire. Your answers will be treated with confidence.
Name: ____________________________________
DOB: _______________
Email: ___________________________________________
Sex: M / F
Phone: ______________________
Address: ____________________________________________________________________________
Emergency Contact: _____________________________
Please place a tick
Phone: _______________________
to indicate ‘yes’ or ‘unsure’.
Have you ever had, or do you have:
Stroke
Diabetes
Epilepsy
Hernia
Gout
Arthritis
Any heart condition
Palpitations or chest pain
Heart murmur
High blood pressure >140/90
Raised cholesterol
Asthma (hospitalised in the last year)
Glandular fever
Rheumatic fever
Dizziness or fainting
Liver or kidney condition
Stomach ulcer
Any major injuries
A family history of heart disease, stroke, raised cholesterol or sudden death in family members under the age of 60?
Are you female over 45, or male over 35, and not used to regular vigorous exercise?
Are you on any prescribed medications?
Have you been hospitalised in the last 12months?
Have you given birth within the last 8 weeks?
Are you pregnant?
Any other condition which may complicate your ability to exercise with us?
_____________________________
If you ticked
any of the above please take this form to your doctor and
request a clearance to commence our exercise program
Please sign below if the condition has already been cleared by your doctor:
Signed: ____________________________
Date: _____________________
Please read the following carefully:
The above information has been answered honestly and if there is a change in your condition in the future you will inform us by filling in this
form again.
Whilst every effort is made to ensure your welfare in our Field of Dreams Fitness programs, there is still a chance of injury. Your participation in
our exercise program is undertaken at your own sole risk and Field of Dreams Fitness shall not be held liable for any claim, whatsoever,
arising from or connected with any of our services provided. No responsibility or liability is accepted for any loss, damage or injury suffered
by you as a result of the use or misuse of any information, content or equipment provided by Field of Dreams Fitness. Field of Dreams Fitness
is released and forever acquitted and discharged from all liability whether personal, or property occasioned to you no matter howsoever
caused in or about the Field of Dreams Fitness training area.
Whilst on the premises, Field of Dreams Fitness takes no responsibility for loss or damage of personal property.
No refunds will be given for payments make in advance. Payments are to be made prior to the commencement date of the block sessions,
otherwise you may ‘pay as you go’ at the required cost. In the event that weather conditions deem exercising unsafe, refunds will not be
given. However, consideration will be made if sessions are cancelled for an entire week or more.
I agree to and understand the above terms and conditions of Field of Dreams Fitness, and
I have answered all the questions to the best of my ability
Signed: _____________________________________________
Field of Dreams Fitness: Sara Kennedy, sara@fieldofdreamsfitness.com.au , 0414184622.
Date: ________________