Pre-Exercise Questionnaire

Thank you for choosing CrossFit North Manly . Please take a few minutes to answer the following questions or work through them with your trainer. Place a to indicate Yes or Not Sure and a X to indicate No. This form and information will be treated as confidential and will not be released without your written consent. Name:__________________________________________DOB:______________Sex:__________ Address:_________________________________________________________Pcode:__________ Occupation:___________________________Phone: W________________M_________________ Email: ____________________________________ Emergency Contact:___________________________W________________M_________________

Exercise History
1.

Are you or have you been exercising or playing sport? If so, please describe.

________________________________________________________________________________ 2. Describe your current health and fitness. ____________________________________________ 3. Have you done CrossFit before? ______________________________

Lifestyle Review
1. Are you following a particular eating plan or diet? __________________________________ 2. Is your job physical or sedentary? _______________________________________________ 3. How much time can you dedicate to an exercise program? ______min/day ______days/week

CrossFit North Manly

www.crossfitnorthmanly.com.au

General Health
Have you had or do you have? Anyone in your family under 60 who has suffered Heart Disease, Stroke or Raised Cholesterol? Are you male over 45 or female over 55 and NOT used to regular vigorous exercise? Are you on prescription medication? Have you been hospitalized recently? Have you given birth in the last 6 weeks? Are you pregnant? Do you have or have you had? Type I Diabetes Type II Diabetes Asthma Glandular Fever Any heart condition Heart Murmer Stroke High Blood Pressure >140/90 Dizziness or Fainting Palpitations or Pain in Chest Liver or Kidney Condition Raised Cholesterol/Triglycerides Stomach or Duodenal Ulcer Arthritis Diabetes Epilepsy Hernia Rheumatic Fever

If you any of the above, please take this form to your doctor and ask for a clearance to exercise before starting any exercise program, OR sign below if you have already cleared the above condition with your doctor. Please give details of condition and related medications of the reverse side of this form. Condition cleared. Signature:_____________________________Date cleared:_______________ Have you ever had or do you have? Any pain or major injuries in the following areas: Neck Back Any muscular pain Knees Ankles Cramps Shoulders Other Are you dieting or fasting? Do you smoke? If so, how many per day?__________________ Are there any other conditions that may be reason to modify your exercise program?__________ ________________________________________________________________________________ If you any of the above, please ask your trainer for exercise/program guidance before starting. What exercise have you been doing recently? ___________________________________________ How long (weeks/months/years):___________ Duration: ____________ How often: ___________ Intensity (please circle): Hard Medium Light

CrossFit North Manly

www.crossfitnorthmanly.com.au

PLEASE READ THE FOLLOWING DISCLAIMER CAREFULLY. I have answered all questions to the best of my knowledge and will inform CrossFit North Manly if any of the information changes. I acknowledge that participating in this physical activity is done at my own risk. I accept all risks and release the CrossFit North Manly from any liability associated with my participation in this physical activity. I acknowledge that participating in this physical activity may involve a risk of injury. I attest to being physically capable of participating in physical activity and a qualified medical practitioner has not advised me otherwise. I am not aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in this physical activity. I will advise CrossFit North Manly immediately if I become aware of any medical condition, injury or impairment in the future. I consent to CrossFit North Manly using any photographs from workouts on their website or in social media. I certify that I am 18 years or older, have read and fully understand this document. Or, as parent/guardian, I agree to the above for myself and on behalf of the participant. I agree to pay all fees as and when due and adhere to the cancellation policy which is that any cancellations within 24 hours of the time of the session will be charged and forfeited. Client Signature: ________________________________________ Date: ___________________ Parent/Guardian Signature: ________________________________ Date: ___________________ Trainer signature: _______________________________________ Date: ___________________

CrossFit North Manly

www.crossfitnorthmanly.com.au