EmailMe Form - Pre-exercise questionnaire

Name *

First Last

Date of birth *

MM / DD / YYYY

Age *

Gender *

Mobile Phone *

Email *

Confirm

Emergency Contact: Name, Rel. *

Emergency Contact: Phone number *

Please answer the following questions by selecting Yes or No on the appropriate Checkbox: *

	Yes	No
1- Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
2- Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
3- Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
4- Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
5- If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
6- Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
7- Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?

IF YOU ANSWERED ‘YES’ to any of the 7 questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise.

If you have a medical clearance please upload a copy including doctor's report here.

you can only upload one file. If is more then one page consider puting them together on a word doc or pdf file.

I understand that I'm participating to activities that include physical exercise. All exercise activities involve a risk of injury. By choosing to participate to this session and any further activities organised by Gabriel Ripamonti and Ripamonti Fitness I voluntarily assume there may be a certain risk of injury. If I experience any pain or discomfort I will listen to my body, adjust or change the exercise, inform and seek assistance from my trainer.
I understand that physical activity is not safe under certain medical conditions and take full responsibility for making the informed decision to participate.
I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against my trainer, Gabriel Ripamonti.
I agree to listen to my body and monitor myself during every training sessions. *

I Agree