Summer Shape Up Pre-Screening Summer Shape Up Pre-Screening Full Name * Phone Number * Email Address * D.O.B * Age * Weight (kgs): * Body Fat Mass (kg) If Known. E.g. Evolt Bio Scan Fat Mass calculation) Bod Fat Percentage If known Height: * Street Number and Name * Suburb * Post Code * Occupation Emergency Contact Name * Emergency Contact Phone Number * How did you hear about Bridget Hicks Fitness? * Flex FitnessWord of mouth/ ReferredFacebookInstagramOther Do you suffer from any of the following? Chest Pain Dizziness Fainting High Blood Pressure Joint Problems Tuberculosis Bronchitis Asthma Diabetes Rheumatic Fever Nephritis Epilepsy Lower Back Pain Are You Pregnant * YesNo Have you ever been told by your doctor to avoid any type of exercise or strenuous activity? * YesNo If YES, please give details Are you currently on any medication that could influence your ability to exercise and/or partake in a nutrition plan? * YesNo If YES, please give details Have you any current injury that may affect your participation in physical activity? * YesNo If YES, please give details 7. Do you have any other medical conditions or injuries that may make it dangerous or difficult for you to participate in physical activity/exercise? * YesNo If YES, please give details Have you worked with a personal trainer before? * YesNo Have you participated in gym-based training before? * YesNo Do you exercise regularly? * YesNo Type of exercise: (e.g. running, weight lifting, group classes etc.) Perceived intensity: HardMediumLightVery light How many times per week? Please indicate any nutrition preferences (vegan, vegetarian etc.), any food intolerances, food allergies, likes and dislikes. The more info here the better! * Please note any particular foods you currently eat that you would like to keep in your diet: * Please indicate what a usual day of eating includes for you (food, beverages, meal timing etc): * Have you dieted before? If so, please give details on what diet/s and your experience (e.g. how long for, did it work for you, why you stopped, how it made you feel etc.): * Any further notes you believe would be beneficial for me to know in order to design your diet: * Have you ever had any eating disorders? Please give details: * What are your main goals and when do you want to achieve them by? * What do you hope to achieve from your participation? Fat loss Weight loss Gain muscle Maintain muscle mass Increase fitness Increase energy levels Increase strength Tone up Improve sport performance Feel better Reduce stress Injury prevention How important is it to you to achieve your goals and why? * Anything else you would like to note as we begin to work together: Risk Warning Acknowledgement and Assumption of Risk Release and Indemnity: I acknowledge that all the information provided above is true and correct and I take it upon myself to inform my personal trainer if any of this change’s. I understand and acknowledge that participating in an exercise program carries with it certain risks that could result in injury to myself or others. I further acknowledge that I am not required to engage in this exercise program and participation in the activities is of my choice and at my own risk. I assume the risk and responsibility for any injury or property damage resulting from my participation in the exercise program. By selecting “I Agree” and further signing this document, you are confirming that you have read and understand it; that you are suitably fit and healthy to participate in this exercise program and hereby waive any and all claims you may have now or in the future against your Personal Trainer in connection with or arising out of your participation in this exercise program. * I AgreeI Disagree and therefore cannot participate Please initial to sign: * If you are human, leave this field blank.
