Burke Body Shop Inquiry Form - Health Screening, Goals and Waiver

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Name *

Age and Profession *

Email *

Address *

Phone number

Emergency Contact (name and number) *

Doctors Name and Number *

Are you looking to Join Classes or get Personal Training? *

Classes

Personal Training

Other:

Please Answer the following questions truthfully ( Check Box if YES ONLY)

Has your doctor ever advised against physical activity?

Do you have/had a personal history of health problems?

Do you have a family history of health problems?

Do you have a personal history of heart problems?

Do you suffer from any persistent/night pain?

Do you have a personal history of high/low blood pressure?

Do you have a personal history of lung problems?

Do you have a personal history of asthma or respiratory problems?

Do you suffer with any pain or limited movements?

Do you suffer with back pain?

Do you have a personal history of epilepsy?

Do you have a personal history of diabetes?

Are you currently taking any drugs or medication?

Are you pregnant or have you been pregnant within the last 6 months?

Do you have any communicable diseases?

Have you had any surgery within the last 12 months?

Have you ever suffered previous injuries? Any injury may be relevant.

Is Stress from Daily living an issue in your life?

If you answered yes to any of the above questions please provide full details here. Please consult with your doctor by phone or in person before starting any new training program or fitness assessment. E.g How many smokes do you have a day? What injury? What level of stress 1 -10 etc. *

What are the main goals you want to achieve? *

Why do you want to achieve these goals/your main reasons for wanting to achieve these and improve your overall health? *

Do you really believe you can make huge change and achieve these goals? *

How long has it been since your trained regularly? *

If you are on a training program at the moment please provide details: *

How would you describe your level of daily activities and movement (be honest!): *

Poor

Active

Very Active

IMPORTANT! Client Agreement - To the best of my knowledge, the above information is accurate and complete. Where I have answered YES, I have consulted with my doctor regarding the issue and he/she has given me permission to engage in this training program. I understand that certain parts of this program are physically demanding, and that I may need to change certain aspects of my lifestyle in order to realise the goals I have set out for myself. I acknowledge that Tony Burke and Burke Body Shop are responsible for providing the coaching I request in helping me get there. I am responsible for my own participation in this program, for my own physical and emotional well-being, and for the achievement of the goals I have set out in this program. Total Release and Waiver of Liability - As a condition of my enrolment, I accept full and complete responsibility for my own ability to participate in this training program in a healthy manner. I understand that instructions, use of equipment etc is potentially hazardous. I hereby release TonyBurke and Burke Body Shop of any injury, damages or loss whatsoever.I have read and understood the above, and understand it sets out the terms of engagement, and that it is a total release and waiver of liability. *

I (Name Above) agree to the above Client Agreement, Total Release and Liability Waiver

I do not agree

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