Studio Athletica Pre-Exercise Health Questionnaire

Please read the following carefully. If you don't understand or have any questions about this form, please contact a staff member from Studio Athletica.

1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?

Stroke:

2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?

Chest Pain

3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?

Faint during exercise

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

Asthma

5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?

Diabetes

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?

Muscle, bone or joint problems

7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?

Other medical conditions

8. Have you spent time in hospital (including day admission) for any medical condition/illness/injury during the last 12 months? If yes, provide details

Time in hospital

9. Are you currently taking a prescribed medication(s) for any medical condition(s)?

Prescribed medication

10. Are you pregnant or have you given birth within the last 12 months?

Pregnant

Conditions

I hereby state that I have read, understood and answered honestly the questions and that any statements made by me in answering the Pre-Exercise Questionnaire are true and accurate. I also state that I wish to participate in activities that may include gymnasium exercise (aerobic and resistance) in a group setting or one on one. I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging an acceptable level of exercise given my knowledge of health and taking into account any medical advice I have received.

I understand that Studio Athletica may reject my application to receive personal training as a result of information provided in this questionnaire, any medical certificate I provide or if Studio Athletica has reasonable grounds for believing that engaging in physical activity may be harmful to my health or safety.

Studio Athletica may retain this Pre-Exercise Questionnaire and the information contained in it for a reasonable length of timer the sole purposes of maintaining complete records of pre-activity applications, verifying previous health/medical history and for assessing any future application for membership by you.


 

I believe that to the best of my knowledge, all of the information I have supplied is correct.

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