Be By Mel Pre Exercsise Forms

PRE EXERCISE
QUESTIONAIRE
GROUP FITNESS & PERSONAL TRAINING
PRE-EXERCISE QUESTIONNAIRE
Be..By Mel strongly suggest that you consult your doctor and obtain
medical clearance prior to commencing any exercise program, as a
certain level of risk is inherent in any exercise program. Any information,
instruction or advice obtained from us may not be substituted for your doctor’s advice and is
THIS IS IMPORTANT TO COM-
PLETE TO MAKE SURE THAT I
AM TRAINING YOU SAFELY AND
AWARE OF ANY ISSUES SO
THAT YOU GET THE MOST OUT
OF YOUR TRAIINING!
Full Name:
Age / Date of Birth:
Address:
Contact Number:
Email:
M / F
CONFIDENTALITY AND PRIVACY
IS MAINTAINED AT ALL TIMES!
Emergency Person & Contact
Detail:
How did you find out about
us?
Do you have, or have you had
Referral (Who: ________________________________)
Website o Community Newsletter o Facebook
Heart Disease (specify)
High Blood Pressure
High Cholesterol
Diabetes
Lung Disorder (asthma, etc.)
No – or None of the above
Have you ever been told you are at risk of
Heart Disease (specify)
High Blood Pressure
High Cholesterol
Diabetes
Stroke
No – or None of the above
Have your ever been told that you have heart problems
Heart Murmur or Valve Defect
Racing Heart
Irregular Beats
Angina or Other
Do you have, or have you experienced
Epilepsy
Fainting
Seizures
Dizzy Spells
Convulsions
No – or None of the above
Have you ever had pain or pressure, either at rest or during exercise
In the middle or, or on the left side of the chest
In the neck region
At the left shoulder or down the left arm
No – or None of the above
Do you take any medications for (please name)
Heart Disease
Diabetes
Cholesterol
Blood Pressure
Asthma/Breathing Problems
No – or None of the above
Do you have any joint or muscular problems that may affect your ability
to train
Y / N
If Yes, please explain:
Do you have any other conditions or injuries that may affect your ability to train Y / N
If Yes, please explain: