EmailMeForm
PRE EXERCISE SCREENING
I warrant to Healthie Fitness that all information I have provided on this form is of a true and correct nature. I accept that I will not have any claims, costs, liability or expenses of any nature against Healthie Fitness for any illness, injury or adverse change in medical condition or state of health arising directly or indirectly from voluntarily participating in any program from Healthie Fitness or associated with Healthie Fitness.
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First
Last
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Country / Region
Email
Phone
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What do you want to achieve from Healthie Fitness?
Reduce body fat
Stress management
Improve muscle tone
Build core strength
Improve confidence
Improve strength
Health and Medical History
Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
*
Yes
No
Do you 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 1 or type 2) 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?
*
Yes
No
If you have a medical condition that is going to affect your participation in physical activity/exercise please state what it is
*
Have you been pregnant recently (within the past 6 months)?
*
Yes
No
Do you suffer from chronic back pain?
*
Yes
No
If you answered YES to any of the questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise and get cleared before signing up. Any questions please email healthiefitness@gmail.com
I have read the Terms and Conditions
*
Yes
I believe that to the best of my knowledge, all of the information i have supplied is correct
*
Yes
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