Name *
Age
Gender MaleFemale
Contact Number
Email
Next of Kin *
Name Of GP / Location
Blood Pressure (If Known)
Exercise Sessions / Week
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? YES/NO * YESNO
2. Do you feel pain in your chest when you do physical activity? YES/NO * YESNO
3. In the past month, have you had chest pain when you were not doing physical activity? YES/NO * YESNO
4. Do you lose your balance because of dizziness or do you ever lose consciousness? YES/NO * YESNO
5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in physical activity? YES/NO * YESNO
6. Is your doctor currently prescribing drugs for your blood pressure or heart condition? YES/NO * YESNO
7. Do you suffer from asthma or need to carry a inhaler with you? YES/NO * YESNO
8. Do you know of any other possible reason why you should not take part physical activity? YES/NO * YESNO
If "YES" please state here:
9. Please state to the best of your knowledge any other reason why physical exercise could have a detrimental effect on your health: YES/NO * YESNO
If you have answered YES to any of the above questions, then you are advised to gain consent from your doctor before participating in the personal training programme, this is your responsibility to do so.
If you have answered NO to all of the above questions and you have assurance of your suitability for: A personal training programme – which will include; a personalised progressive programme designed around your needs and short, medium and long-term goals. The programme will work all components of physical fitness and use the principles of training to ensure it is a gradual periodised programme of exercise and physical activity. You are advised to postpone entry into the programme if you feel unwell or have a temporary illness. You must inform your personal trainer of any changes to your health status, whilst engaged in your training programme. By completing and submiting this form, you are confirming that all the information given is true. If you fail to do so or do not seek advice from your GP on any questions answered YES above, CC Professional Fitness will not accept any responsibility for the consequences.
I understand that full payment will still apply for cancellations made under 24 hours before the scheduled session
Name
Date
Parent / Guardian (Under 18)
4 + 0 = ? Please prove that you are human by solving the equation *
