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Chocolate Fitness

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Pre-Exercise Screening Questionnaire

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Name:_________________________________Phone:________________

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Emergency Contact:______________________Phone:________________

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​

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Email__________________________________

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Medical Info:

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Have you ever had any of the following, if so which?

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1. Heart: High blood pressure, high cholesterol, pain tightness in chest, heart/stroke

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condition?

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_______________________________________________________________

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2. Allergies: Anaphylaxis, asthma or breathing difficulties?

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_______________________________________________________________

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3. Pain: Knees, neck, back, shoulder, elbow?_____________________________________

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Physio/Chiro/Specialist______________________Contact:__________________________

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4. Fitness Record: Have you exercised in the past 12 months? If so what was your program/sport?

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____________________________________________________

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5. Injuries/Surgery: Do you any injuries which might hinder your exercise program- is so, what?

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____________________________________________________

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Any recent surgery – if so what?____________________________________________________

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6. Conditions: Do you have any conditions/health concerns that may hinder your exercise?

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____________________________________________________

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I __________________________ understand and acknowledge that I will be participating in all activities with Chocolate Fitness at my own risk.Chocolate Fitness will not be liable for any loss of property, damage or injury I may sustain whilst participating in, or as a result of participating in, any activities prescribed by Belinda Eady and Daniel Myers of Chocolate Fitness.I understand that the safety and welfare of any accompanying children are my sole responsibility.I will ensure that the instructor is fully aware of the whereabouts of any required medications such as ventolin/epipens.

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Signed:_________________________ Date:______________________

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