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PLEASE REGISTER (only required once)
This form must be completed before you commence training with or receive a personalised program from BB Body Fitness.
This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Exercise & Sports Science Australia, Fitness Australia or Sports Medicine Australia for any loss, damage or injury that may arise from any persons acting on any statement of information contained in the tool.
Personal Details
Name
*
First
Last
Gender
*
Male
Female
Other
Date of birth
*
DD
/
MM
/
YYYY
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Email
*
Best Contact Phone Number
*
Medical History
1.
Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
*
Yes
No
2.
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
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Yes
No
3.
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
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Yes
No
4.
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
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Yes
No
5.
If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
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Yes
No
6.
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?
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Yes
No
7.
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
*
Yes
No
IF YOU ANSWERED ‘YES’ to any of the 7 questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise
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I understand
IF YOU ANSWERED ‘NO’ to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate-high intensity physical activity/exercise
*
I understand
If I experience any problems or side effects I must report them immediately and make the necessary adjustments to my activity with my medical provider and BB Body Fitness
*
I understand
Do you smoke
Yes
No
Current Activity
What exercise are you currently doing?
How long have you been doing this exercise?
How often do you exercise?
What are your health and fitness Goals?
Just in case we missed something
Are there any other concerns or health issues of any description that we should know about to help optimise injury prevention?
*
E.g. low back pain, recently gave birth, taking blood pressure medication, recent operation/ surgery, shin splints , etc. the greater the detail the better. If nothing, then just write N/A.
Services
Please describe what qualities you are looking for in a personal trainer.
*
E.g. I like a trainer who is empathetic but still pushes me... or I want to be spoken to in a direct manner, no beating around the bush.
What are the services you wish to receive from us?
*
Personal Training
Free Consultation
Online Coaching (includes program and regular contact)
Google Sheets Program
Other
If "Other" Please describe.
What style of support suits you best?
Select what you feel would help you best achieve your goal
*
Video call 2x per week
Video call once upon 6 weeks training block
Other
If "Other" Please describe.
What services of support are you wanting most?
*
Exercise Support Only
Nutrition Support Only
Exercise and Nutrition Support
How did you here about us?
Crunch Fitness
Word of Mouth
Social Media
Website
Other
If "Other" Please describe.
I authorize bb body fitness, exercise index and Brendan Burchall to take and use any
Photographs/videos or media in any publication, production or presentation,
including electronic/internet marketing material for the purpose of education, information and promotion. All associations will use this in a positive manner.
Yes
No
Declaration
I acknowledge and agree that I will use equipment prescribed at my own risk and I release BB Body Fitness and any business associated with Brendan Burchall from any liability of injury or loss caused to me by my exercising,training and/or use of equipment, except where such loss is caused by negligence of BB Body Fitness and any business associated with Brendan Burchall. I also grant Brendan permission to share my information with Belinda Jones for relevant nutritional services when nutritional components have been requested, this information may be used to gain contact from Belinda for nutritional coaching under her methods.
Terms and Conditions - PLEASE READ CAREFULLY
I acknowledge that payments will be direct debited on a weekly basis on the Monday, if you wish to suspend payments you may, however, notice must be given and received by Brendan prior to withdrawal. If you wish to finish online training the same rule applies but when quitting you will lose access to all your resources.
If you are sick and unable to train for the week, send a photo of a MEDICAL CERTIFICATE Whatsapp or email. if a medical certificate can be provided a refund may be arranged if you were unable to train on a particular week.
THANK YOU FOR UNDERSTANDING.
By checking the "I agree" button I am declaring that the information provided above is correct, I agree with the above deceleration, terms and conditions and this act is equivalent to/ and holds the legal status of a personal signature.
*
I agree
Signature
*
Clear
Please use your mouse or touch screen to sign.
Note:
Once you have submitted, you can go ahead and book online. Registration is not booking, it allows us to provide better care. Thank you for your time :)
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