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WELCOME SHEET – CLIENT INFORMATION
Please fill in your details below
Name
(Required)
First
Last
Gender
(Required)
Select
Male
Femaie
Date of Birth
(Required)
MM slash DD slash YYYY
Full Address (Street, City, Postcode)
(Required)
Phone Number
(Required)
E-Mail
(Required)
CLIENT INFORMATION – HEALTH QUESTIONNAIRE (PAR-Q)
Please read the questions carefully and answer each one honestly:YES, NO or N/A
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
(Required)
Yes
No
N/A
Do you feel pain in your chest when you do physical activity?
(Required)
Yes
No
N/A
In the past month, have you had chest pain when you were not doing physical activity?
(Required)
Yes
No
N/A
Do you lose balance because of dizziness or do you ever lose consciousness?
(Required)
Yes
No
N/A
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
(Required)
Yes
No
N/A
Is your doctor currently prescribing drugs (for example water pills) for blood pressure or heart condition?
(Required)
Yes
No
N/A
Do you know of any other reason why you should not do physical activity?
(Required)
Yes
No
N/A
Are you pregnant?
(Required)
Yes
No
N/A
If so, how many weeks pregnant are you?
Are you taking any medication from your doctor?
(Required)
Yes
No
N/A
f you have recently has a baby, have you been given the post-natal 6 weeks check by your midwife or doctor?
(Required)
Yes
No
N/A
Have you been given permission to exercise by your midwife or doctor following your post-natal check?
(Required)
Yes
No
N/A
Have you experienced any complications during pregnancy/birth or postpartum?
(Required)
Yes
No
N/A
If you answered yes to any of the above, please give details below
(Required)
I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction
Client information – Liability waiver
I am aware of the risks in observing or participating in the activities offered by EH Fitness and I understand that all sports or fitness that I will execute and participate in are entirely at my own risk and perils. I assume complete responsibility and liability for those risks and for the injuries that may occur as a result of these risks, even if injuries occur in a manner that is not foreseeable at the time I sign this agreement. I realise that by voluntarily assuming the risks involved, I will be solely responsible for any loss or damage I sustain, including personal injuries to me or damage to my property.
I Agree to the above Liability waiver
Date
(Required)
MM slash DD slash YYYY