Pre Exercise Form

Please complete this form prior to training with Matrix Health and Fitness

Your Details

First Name *

Last Name *

Email Address *

Phone *

Date of Birth *

Occupation *

Address *

Suburb *

Postcode *

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Questionnaire

Job activity *

Physical Sedentary

Are you currently exercising or playing any sport? *

Yes No

Health & Medical Check

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

Yes No

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

Yes No

3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise? *

Yes No

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

Yes No

5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar in the last 3 months? *

Yes No

6. Do you have any other conditions that may require special consideration for you to exercise? *

Yes No

If you have answered YES to any of the above 6 questions you are required to seek guidance and a MEDICAL CLEARANCE LETTER from your medical practitioner prior to you training with Matrix Health and Fitness.

7. Do you currently exercise for less than 1.5 hours per week? *

Yes No

8. Age *

8a. Gender? *

Male Female Other

9. Do you smoke cigarettes or have you quit smoking in the last 6 months? *

Yes No

10. Have you been told that you have high blood pressure? *

Yes No

11. Have you been told that you have high blood sugar (glucose)? *

Yes No

12. Have you been in hospital in the last 12 months? *

Yes No

13. Are you currently pregnant? *

Yes No

14. Have you given birth within the last 12 months? *

Yes No

15. If you have any injuries/illnesses NOT listed above then please give more information

Based on the information you have supplied in questions 7 to 19 a MEDICAL CLEARANCE LETTER from your medical practitioner MAY still be required prior to training with Matrix Health and Fitness. We will advise if this is required.

How did you hear about us? *

I agree that all information I have provided to Matrix Health and Fitness is of a true and correct nature. I accept that I will not have, nor make any claim of any nature against Matrix Health and Fitness for any illness, injury or adverse change in medical condition or state of health arising directly or indirectly from any program or advice provided by or carried out preparatory to or as part of any program I undertake whilst under the supervision or instruction of Matrix Health and Fitness. Any rights granted to me by law which are not capable of change by agreement remain unaffected by the terms of this agreement.

I agree to the Declaration above *