First name
Last name
Your email
Phone Number
Gender MaleFemale
Date Of Birth
Street Address
Apartment, Flat etc
Town
County
Postcode
Emergency Contact First name
Emergency Contact Last name
Emergency Contact email
Emergency Contact Phone Number
Please take 3 minutes to answer the following questions. Just place a tick in the boxes to indicate 'Yes' or 'Not Sure'.
Have you ever had or do you have? Anyone in your family under 60 suffered Heart Disease, Stroke, raised Cholestrol or Sudden Death?Are you male over 35 or female over 45 and NOT used to regular vigorous exercise?Are you on any prescribed medication?Have you been hospitalised recently?Have you given birth within the last 6 weeksAre you pregnant?Do you have any infections or infectious diseases?
Have you ever had or do you have? GoutLiver or Kidney conditionAny Heart conditionStrokeGlandular FeverHeart murmurDiabetesRheumatic FeverHigh blood pressureEpilepsyDizziness or faintingPalpitations or pains in the chestHerniaStomach or Duodenal UlcerRaised Cholesterol / Triglycerides
If you ticked any boxes above, please give details of conditions, medication and approximate date cleared
If you ticked one or more boxes in this form please contact your doctor and ask for clearance to exercise before starting any exercise programme OR Tick the below box and declare which condition(s) you have cleared with your doctor.
Have you ever had or do you have? ArthritisAsthmaCrampsMuscular PainTick if you smoke
Any pain or injuries particularly in the following areas? NeckBackKneesAnkle
I have cleared the following conditions with my doctor:
Are there any other conditions which may be reason to modify your exercise programme?
Should you suffer any illness or condition in the future PLEASE tell us by completing this form again.
STATEMENT: I appreciate that there are risks associated with physical exercise and I accept full responsibility for ensuring I am fit and well enough to safely partake in any fitness activity with MP Personal Training. Therefore I agree to indemnify MP Personal Training against all problems whatever may arise from participation in exercise; MP Personal Training is isured for its legal liabilities. *
I have read and understood the above statement
Consent Confirm that the information provided is accurate and consent to its use.
