Pre-Training Questionnaire

Please complete the questions below before your first session. It is important that you disclose ALL existing medical conditions, to determine whether medical advice is required before commencing an exercise program. This questionnaire does not provide medical advice in any form and does not substitute advice from a qualified Medical Practitioner.

Full Name

Phone Number

Date of Birth

Address

Emergency Contact Name & Phone Number

What is your current level of physical activity:

I have not exercised in the last 6 months

I exercise once per week or less

I exercise 2-3 times per week

I exercise 4 r more times per week

If you answer yes to any of the below questions, please include all relevant details in the box below and seek clearance from a Medical Practitioner before participating in exercise.

Has a doctor ever told you that you have a heart condition or have you ever suffered a stroke?
Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
Do you ever feel faint, dizzy or lose balance during physical activity/exercise?
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
If you have diabetes (type l or type ll) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
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?
Do you have any other conditions that may require special consideration for you to exercise?
Do you suffer from high blood pressure (over 140/90) or low blood pressure (below 100/80)?
Are you pregnant?

I acknowledge that if I answered yes to any of the above questions, I am currently under the supervision of a Medical Practitioner who has approved my participation in this exercise program.

Declaration:

I acknowledge the above information is accurate and complete.

In the case that my medical condition changes over the course of my participation in this exercise program I will inform Daybreak Fitness.

I declare the above information is accurate & complete. I agree to the terms as laid out on the Policies page of this website. View Policies