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Contact Us
Focus Health & Fitness – Pre-Exercise Questionnaire | Personal Training | Stretch | Holistic Health
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Focus Health & Fitness – Pre-Exercise Questionnaire | Personal Training | Stretch | Holistic Health
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URL
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Name
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Today's Date
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MM slash DD slash YYYY
Phone
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Email
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Your Date of Birth
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MM slash DD slash YYYY
Sex
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Height
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Weight
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Address
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Street Address
City
State / Province / Region
ZIP / Postal Code
Emergency Contact Details
Name
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Phone
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Relationship
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Do you now, or have you had in the past, any of the following: (please answer all questions, yes or no)
History of heart problems, chest pain, or stroke?
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Yes
No
Details of heart problems, chest pain, or stroke
Increased blood pressure?
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Yes
No
Details of increased blood pressure
Any chronic illness or condition?
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Yes
No
Details of chronic illness or condition
Difficulty with physical exercise?
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Yes
No
Details of difficulty with physical exercise
Advice from doctor not to exercise?
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Yes
No
Details of Hernia, or any condition that may be aggravated by lifting weights?
Recent surgery (last 12 months)?
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Yes
No
Details of recent surgery
Pregnancy (now or within last 12 months)?
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Yes
No
Details of Pregnancy (now or within last 12 months)
History of breathing or lung problems?
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Yes
No
Details of History of breathing or lung problems
Muscle, joint, or back disorder, or previous injury?
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Yes
No
Details of Muscle, joint, or back disorder, or previous injury
Diabetes or thyroid condition?
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Yes
No
Details of Muscle, joint, or back disorder, or previous injury
Cigarette smoking habit?
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Yes
No
Details of Cigarette smoking habit
Obesity (more than 20% over ideal body weight)?
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Yes
No
Details of Obesity
Increased blood cholesterol?
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Yes
No
Details of Increased blood cholesterol
History of heart problems in immediate family?
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Yes
No
Details of History of heart problems in immediate family
Hernia, or any condition that may be aggravated by lifting weights?
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Yes
No
Details of Hernia, or any condition that may be aggravated by lifting weights
Do you ever experience dizziness, fainting or light-headedness during or after physical activity?
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Yes
No
Details of dizziness etc
Are you currently engaging in regular physical activity on most days of the week?
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Yes
No
Details of physical activity
Do you experience high levels of stress, anxiety, or other mental health concerns?
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Yes
No
Details of stess, anxiety or other
Information: Are you taking any medications/drugs?
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Yes
No
Details of medications/drugs
Consent
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I agree to GENERAL TERMS, CONDITIONS and DISCLAIMER
These terms and conditions relate to the operation and function of FHFPT Pty Ltd, trading as Focus Health & Fitness and its subsidiaries, affiliates, and associated parties regardless of their location. Nothing in these terms and conditions, limit any rights you may have under the Trade Practices Act, Fair Trading Act, any other Commonwealth or State Legislation or any other such laws in the region where you attend related activities. You acknowledge and recognise the inherent risks of injury or ill health resulting from use of the services and from participation in exercise generally. In consideration of participation in activities with Focus Health & Fitness you agree to release and indemnify Focus Health & Fitness and any company associated with Focus Health & Fitness. You agree to participate in all activities at your own risk and responsibility whether supervised or not by staff. You agree to release and hold harmless Focus Health & Fitness and any associated parties from and against all actions which may be bought by you or on behalf of you in respect of any incident arising out of injury, loss, damage or death caused to you or your property in any way what so ever.
Contact Form
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