Client Information Form

PLEASE NOTE:

THAT ANY PARTIES BELOW THE AGE OF 18 MUST OBTAIN CONSENT FROM THEIR LEGAL GUARDIAN AND ENSURE THAT THE PERSONAL TRAINING AGREEMENT AND ALL SUPPORTING DOCUMENTS ARE SIGNED ON BEHALF OF THE MINOR. THE GUARDIAN WILL BE LIABLE FOR THE PAYMENT OF THE ACCOUNT.

SHOULD AN ORGANISATION APPOINT THE SERVICES OF THE COMPANY FOR THEIR EMPLOYEE PARTICIPATION, THE ORGANISATION SHALL BE LIABLE FOR ALL COSTS ASSOCIATED WITH THE COMPANY’S APPOINTMENT AND TO ENSURE THAT EACH EMPLOYEE COMPLETES THIS CLIENT INFORMATION FORM AND THE INDEMNITY AGREEMENT – ANNEXURE “B”

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Name *

First

Last

Date of Birth *

Age *

Email *

Gender *Select optionMaleFemale

Residential address *

City *

Postal code *

Phone *

Do you have medical aid? *

• Yes
• No

Recorded for medical emergencies

Emergency Contact 1 *

First

Last

Relationship to emergency contact *

Phone *

Emergency Contact 2 *

First

Last

Relationship to emergency contact *

Phone *

MEDICAL INFORMATION

• High Blood Pressure
• Pain/Tightness in chest
• Diabetes
• High Cholesterol
• Muscle Pain/Cramps
• Back Pain/Joint Pain
• Heart/Stroke Condition
• Dizziness or Fainting
• Arthritis
• Asthma/Difficulty Breathing
• Epilepsy
• None of the above

Have you ever had, or do you have any of the following? (Please tick all that apply to you)

Additional information

If you selected any of the above, please provide additional details

Medical Clearance

• High Blood Pressure
• Pain/Tightness in chest
• Heart/Stroke condition
• Dizziness or Fainting

If you have selected any of the above cardiac risk factors, you should see a doctor for a medical clearance before starting the fitness/wellness program.

Do you have any injuries that may hinder your participation in the fitness/wellness program? *YesNo

Select Option

Describe your injury

If you have answered yes to the previous question, please describe the injury:

Do you smoke? *YesNo

Select Option

If no, have you quit in the last two years? *YesNo

Select Option

Is there anything that we should know that may limit your activity or participation on our fitness/wellness program? *YesNo

Select Option

Are you currently take medication? *YesNo

Select Option

If yes, what is the medication you are taking?

Has a doctor imposed any activity restrictions? If so, please describe *

Do you engage in regular exercise/sport? *YesNo

If yes, describe the nature of the program. E.g. cardiovascular, weight program

What are your goals our of this fitness/wellness program? (Please Tick which ones apply to you) *

• Body fat reduction
• Muscular strength
• Muscular definition
• Social
• Weight loss
• Cardiovascular fitness
• General Wellbeing
• Increased flexibility
• Try something new
• Other (Please specify)

Other

Current weight *

Current height *

How many sessions do you aim to attend? (Per week) *

What is your short-term goal? (8 Weeks) *

Overall, how would you describe your nutritional intake? Please choose one only *

• Poor
• Average
• Good
• Excellent

If your attendance becomes irregular and you don't make your weekly attendance goal, do you give us permission to contact you to offer support? *YesNo

If there is any other information you think we should know please us the space below:

I HAVE ANSWERED ALL QUESTIONS HONESTLY AND COMPLETELY TO THE REST OF MY ABILITY *

• Yes
• No

Submit