OutFit Health Questionnaire

OutFit Online Health Screening Form

Subject *

Please do not alter this field above

Your Name *

Email Address *

Date of Birth *

Gender *

Female
Male

Address *

Phone *

Occupation

Height (cm)

Body Weight (kg)

Emergency Contact Name & Phone Number

Known conditions

Do you have (or have you had) any condition that could prevent or hinder an exercise programme?

For example: cancer, diabetes, stroke, heart disease, asthma, osteoporosis, arthritis, mental illness, aids, liver or kidney disease, hepatitis, epilepsy, anaemia etc?

Have you had any medical procedures or surgery that may affect your ability to exercise?

For example: knee or hip replacement, hernia, spinal fusion etc.

Do you have any existing strains or sprains that your trainer should be aware of?

Do you currently take any regular medications?

Please give the name of the medication and the condition that it is treating

Do you suffer from back pain?

Is there the possibility that you are pregnant?

Do you take medication for depression?

Signs and symptoms

Do you experience any of the following?

Pains in your chest, especially with exercise?
Feel faint or have dizzy spells, particularly with exercise?
Get the feeling that your heart is skipping beats or beating abnormally fast during or after exercise?
Swelling or an accumulation of fluid about the ankles or pain in your legs after exercise (other than muscular soreness)?
Difficulty with your eyes, vision or hearing (other than wearing glasses or contact lenses) which may affect your ability to follow instruction?
None of the above

If you have checked any of the above boxes please supply more information

Cardiac risk factors

Do any of the following apply to you

I have a close relative (ie father, mother, brother, sister) who has had a stroke, heart attack or cardiovascular disease
My doctor has told me that I have high blood pressure
My doctor has told me that I have high cholesterol
None of the above

Do you smoke cigarettes daily? How many?

Exercise background

What is your background with sport and exercise activities.

Type of exercise and duration of participation.

How long have you been maintaining an exercise regime of some sort (years)?

Future exercise plans

How often do you plan to exercise? Both with Out-Fit and on your own (please give details).

What time of day do you prefer for your workouts?

What location do you prefer for your workouts?

What type of exercise intensity do you prefer?

What parts of your body do you feel need the most improvement?

How would you rate your activity levels at work?

Do you have any special requirements or concerns relating to your exercise programme?

Do you have any exercise equipment at home?

For example, treadmill, punching bag, weights etc.

How did you find out about Out-Fit?

Google
Friend
Saw your van
Other

Acknowledgement release and assumption of risk
WARNING
This is an important document, which affects your legal rights and obligations. Please read it carefully and do not sign it unless you understand it. If you have any questions please ask.
Acknowledgement of Risks, Injury and Obligations
I acknowledge that the activities I am to undertake have potential dangers and by participating in them I am exposed to certain risks. I acknowledge and understand that whilst participating in any such activities:
• I may be injured, physically, mentally, or may die.
• Any physical conditions I may have, of which I may or may not be aware, of which I may or may not have disclosed to Out-Fit Outdoor Fitness or its staff & trainers, may be aggravated or worsened by my participation.
• My personal property may be lost or damaged.
• Other persons participating in such activities may cause me injury or may damage my property.
• I may cause injury to other persons or damage their property.
• The conditions in which activities are conducted may vary without warning.
• There may be no or inadequate facilities for treatment or transport of me if I am injured.
• I assume the risk of, and the responsibility for any injury, illness death or property resulting from my participation in any activities.
Release and Indemnity to Out-Fit Outdoor Fitness and it's staff & trainers
In consideration of the acceptance of my payment (or guest status) for participating in any activity (and except to the extent that the same may be precluded by statute) I agree to release and indemnify Out-Fit Outdoor Fitness and staff & trainers as follows:
• I participate in the activities at my sole risk and responsibility.
• I release, indemnify and hold harmless Out-Fit, its staff & trainers, from and against all and any actions or claims which may be made by me or on my behalf or by other parties for or in respect of or arising out of injury, loss damage or death caused by me or my property in any way, whatsoever. I also agree that in the event that I am injured or my property is damaged, I will bring no claim, legal or otherwise, against Out-Fit in respect of that injury or damage.
• I acknowledge that I have either had a physical examination and been given my physician’s permission to participate, or that I have decided to participate in the activity and use of the equipment without the approval of my physician and assume all responsibility for my participation, and utilisation of equipment during the activities.
• I acknowledge and agree that no warranties or representations have been made to me by Out-Fit or it's staff & trainers regarding the results I will or may achieve from any program conducted by Out-Fit. I understand that results are individual and may vary.
• Before signing this document I have read and understand it and know how it affects my legal rights.

I have read and understood the above terms. *

Please type your name as a signature that you agree to these conditions *

If you are under the age of 18 years, this panel must be signed by a parent or guardian

OutFit Outdoor Fitness

Personal Training & Group Fitness, Camden NSW

Personal Training & Group Fitness, Camden NSW

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