Your Name*
Age*
Date of Birth*
Your Email* (required)
Phone Number*
Home Address
GP/Doctor's NAME or Emergency contact NAME *
Emergency contact NUMBER *
Are you currently taking ANY medication? * YesNo
If you are on, or just coming off, medication then please detail below, including any relevant information that may impact your safety.
Are you pregnant or have given birth in the last 3 months? * YesNo
Please detail any specifics regarding pregnancy/birth that may impact your safety
Is there a history of heart problems or chest pain in your family or with you? * YesNo
If yes please detail below
Do you have HIGH OR LOW blood pressure? * Yes - HIGHYes - LOWNo
Do you have difficulty with physical exercise or advice from your GP to avoid specific movements? * YesNo
Do you have Diabetes? * YesNo If yes please detail below
Do you have any muscle, joint or back disorders that could be aggravated by physical exercise?* YesNo If yes please detail below
Have you a recent surgery? (within last 3-6 months?) * YesNo If yes please detail below
Do you have Asthma or trouble breathing? * YesNo If yes please detail below
Do you have ANY chronic illness? * YesNo If yes please detail below
Do you have high blood cholesterol levels?* YesNo
Do you ever feel faint, dizzy or light-headed? YesNo If yes please detail below
Do you have any conditions that will prevent you from performing exercises ranging from high impact moves, running, pressing, lifting and an elevated heart rate? * YesNo If yes please detail below
Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days?* YesNo
Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?* YesNo
Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2 metres for more than 15 minutes accumulative in 1 day)?* YesNo
Have you been advised by a doctor to self-isolate at this time? YesNo
Have you been advised by a doctor to cocoon at this time? YesNo
Do you consider yourself to be in the category of people at higher risk from coronavirus? YesNo
If your situation changes after you complete and submit this form you agree to inform your therapist/instructor and / or clinic management YesNo
F YOU HAVE ANSWERED 'YES' TO ANY OF THE ABOVE, OR HAVE ANY OTHER INFORMATION TO DISCLOSE REGARDING YOUR HEALTH OR INJURY HISTORY PLEASE DETAIL HERE AND YOUR COACH WILL SPEAK TO YOU BEFORE YOUR TRAINING COMMENCES. IT IS ALSO WORTH NOTING THAT THE MORE YOU LET US KNOW REGARDING BUMPS, KNOCKS, NIGGLES, PAINS, ACHES, BROKEN BONES, TRAUMA ETC THE MORE WE WILL KNOW TO HELP YOU WITH. IT WILL HELP US UNDERSTAND THINGS WE SEE MUCH MORE QUICKLY. EVERYTHING MATTERS, SO TAKE YOUR TIME AND WRITE DOWN EVERYTHING YOU CAN THINK OF
By signing this you agree that all the information above is correct as of todays date and that if there are any changes to your health you will notify your trainer. You are aware that training of any kind involves risks, and that adequate care, attention and instruction will be given for each specific exercise. If you are ever in doubt about something you hereby agree to communicate clearly in asking for help. And, last but not least, please note that there is photography/video taken from time to time. It's how we tell our story/spread our message. We paint everyone in a good light, naturally. If you are hesitant to be pictured, for whatever reason, please chat to us and we will be mindful of minimising your presence in any pictures/video, understanding that there will most likely be some form of inclusion due to the size of the studio. With that said, by signing below you understand that you are in an environment where picture and video is taken for the purpose of storytelling on social media. *
Signed*
Todays Date* I agree to BodyFix Terms & Conditions & Privacy Policy: YesNo
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