Pre-Exercise Questionnaire Personal informationYour Name(Required) First Last Your email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Date of birth(Required) MM slash DD slash YYYY Occupation(Required)Person to be conacted in case of accidentName(Required) First Last Phone(Required)Medical historyHave you ever had or do you have? Please tick all that apply Rhematic Fever Gout Any Heart Condition Glandular Fever Diabetes Heart Murmur Dizziness or Fainting Epilepsy Family History Heart Disease Stomach or Duodenal Ulcer Liver or Kidney Condition Palpitations or Pain in Chest Hernia Asthma Stroke Any Infectious Diseases Arthritis High Cholesterol Chronic Cough Regular Headaches High/Low Blood Pressure Injury / illness description:Do you have any pain or major injuries in the following areas? Please tick all that apply Neck Back Shoulders Knees Ankles Muscular Pain Description:Are you on prescription medication? Yes No If yes, please describe:Do you believe you are pre-menopausal or going through menopause? Yes Have you ever been diagnosed or told you have PCOS, endometriosis or something similar? Yes Do you ever leak or pee a little when you cough, pick something up, jump, run or something similar? Yes Tell us moreIf you have given birth, was it vaginal and/or a Caesarian? Vaginal Caesarian Tell us more (dates, complications during pregnancy/birth etc.)Who did you seek post-birth treatment and clearance from?What are your key exercise goals?When do you want to achieve these goals?Is there anything you can think of that could prevent you from achieving these goals?Describe in one or two words how you feel about your health, well being and body-shape today?How much time can you dedicate to an exercise program? Min per day/days per weekHave you been exercising or playing sport in the last 12 months? If so, please describeAre you currently exercising? Yes No Sometimes Did you/are you getting the results you expect?Have you had a personal trainer before? Yes No What are some of the things about having a personal trainer that you enjoyed? If no, what are you expecting from personal training?Anything else you'd like to tell us?Accept Terms(Required) I have read and accept the client contract, terms & conditions and cancellation policy. The 'Trainer' refers to the Australian Registered Business 'Innervate Health & Fitness'. The 'Activity' refers to the participation in personal/group strength, fitness and conditioning training. I acknowledge that a condition of participating in this activity is that I do so at my own risk. I accept all risks and hereby indemnify and release the trainer, their agents, affiliates, employees, and any person directly and indirectly associated with the trainer against all liability claims, demands and proceedings arising out of or connected with my participation in this activity. I acknowledge that participating in this activity may involve a risk of serious injury or even death from various causes including: over exertion, dehydration, equipment failure and accidents with equipment and surroundings. I recognise the difficulties associated with the activity and attest that I am physically fit to participate safely in the activity and that a qualified medical practitioner has not advised me otherwise. I understand the demanding physical nature of this activity. I am not aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in this activity. In the event that I become aware of any medical condition, injury, or impairment that may be detrimental to my health if I participate in this activity, my trainer will be immediately be informed. By continuing to participate in this activity I accept the risks, despite these conditions and am still and will always be under the terms of this agreement. I certify that I am 18 years or older and have read this document and fully understand it OR as a parent or guardian of the participant (a) I agree to the above for myself and on behalf of the participant and (b) I indemnify and will keep indemnified any person or body directly or indirectly associated with the conduct of the activity on the terms referred to I have a read, understand and agree to the trainers policies (as disclosed in the client contract).
