Fitness Class Screening Form Personal Details & Screening Form First Name Last Name Email Age Date of Birth Mobile Number Home Address GP Name or Emergency Contact Name GP Name or Emergency Tel. Number Are you currently taking any medication? Yes No If you are on, or just coming off, medication then please detail below, including any relevant information that may impact your safety. Are you pregnant or have given birth in the last 3 months? Yes No Please detail any specifics regarding pregnancy/birth that may impact your safety Is there a history of heart problems or chest pain in your family or with you? Yes No If Yes please give the details below Do you have HIGH OR LOW blood pressure? Yes (High) Yes (Low) No Do you have difficulty with physical exercise or advice from your GP to avoid specific movements? Yes No If Yes please give details below Do you have Diabetes? Yes No If Yes please give details below Do you have any muscle, joint or back disorders that could be aggravated by physical exercise? Yes No If Yes please give details below Have you had a recent surgery? (within last 3-6 months?) Yes No If Yes please give details below Do you have Asthma or trouble breathing? Yes No If Yes please give details below Do you have ANY chronic illness? Yes No If Yes please give details below Do you have high blood cholesterol levels? Yes No Do you ever feel faint, dizzy or light-headed? Yes No If Yes please provide details below If you have answered YES to any of the above, or have any other information to disclose regarding our health or injury history, please provide us with the details here. Hanna needs to know and will speak to you about it. Please keep ShapeUp fitness apprised of any niggles, bumps or knocks. The more we know the more we can help. Please don’t skip this part, information can help us get you to the fitness level you would like. By signing this you agree that all the information above is correct as of todays date and that if there are any changes to your health you will notify your trainer. You are aware that training of any kind involves risks, and that adequate care, attention and instruction will be given for each specific exercise. If you are ever in doubt about something you hereby agree to communicate clearly in asking for help. Today's Date Submit
