Flex Fitness Member Pre Screen Form

Club Location*

Personal Details

Name*

First Last

D.O.B*

Contact Number*

Email*

Gender*

Male
Female
Other

Lifestyle

How do you consider your diet to be?

Good
Sufficient
Poor

How do you rate your stress levels?

High
Moderate
Low

Do you smoke?

Yes
No

Includes vaping.

Do you consider your current lifestyle to be active?

Yes
No

An active lifestyle consists of having an active job and/or regular exercise.

Medical History

Please answer these questions to the best of your knowledge.

How long has it been since your last GP visit or check-up?*

Have you had any major injuries/surgery in the last 12 months?*

Yes
No

If yes, please specify:

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

Yes
No

Do you ever feel faint or have dizzy spells during exercise that causes you to lose your balance?*

Yes
No

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

Yes
No

If you have diabetes (type I or type II), have you had trouble controlling your blood glucose in the last 3 months?*

Yes
No

Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?*

Yes
No

If you answered YES to any of the above questions, please seek guidance from our staff. You may need to provide a medical clearance from your GP or appropriate health professional prior to undertaking physical activity. However, if you do not wish attain a referral from a medical practitioner, you may sign the release waiver below stating that you (named above) understand the risks associated with exercise. You understand that this is an unsupervised fitness club and assume all risks associated with using exercise equipment in Flex Fitness without the aid and supervision of staff members on the premises. If you answered NO to all of the questions above and you have no other concerns related to your health, you may proceed to undertake moderate intensity physical activity by signing this waiver.

Date*

Release Waiver*

I hereby acknowledge that:

• The information provided above regarding mine/my child’s health is, to the best of my knowledge, correct.
• I will inform you immediately if there are any changes to the information provided above.
• I give permission for myself/my child to participate in physical activity within Flex Fitness.
I acknowledge that participating in physical activity carries a risk and I accept all responsibility for that risk. I have been explained the rationale for collecting this information and understand the risks associated with choosing not to advise Flex Fitness Personnel of my medical history.

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Flex Fitness - Health Screen

Personal Details

Lifestyle

Medical History