Name: EverMotion - Personal Trainer Armadale
Address: Llaneast St, Armadale, VIC, 3143
Telephone: +61 417 030 751

HEALTH FORM

Name*
First Name Surname
How I found out about EverMotion*
Email Address*
Postal Address*
Phone*
Birth Date*
Gender*
Occupation*
Company
Emergency Contact Person
Name*
Relationship to you*
Email
Phone*
Current Exercise
Briefly outline your weekly exercise schedule
Exercise Goals
List your 3 main health & fitness goals in order of priority (please be as specific as possible)
1.*
2.
3.
Health History
Do you smoke / have you recently quit?*
- Yes
- No
How many alcoholic drinks do you consume each day (if any)?*
Do you believe you have a healthy & well-balanced food intake?*
- Yes
- No
How many glasses of water do you drink each day?*
Medical Conditions

Please check YES if you have (or have had) any of these conditions

	Yes	No
1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?

IF YOU ANSWERED ‘YES’ to any of these 7 questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity.
Please check the boxes below if you have (or have had) any of these conditions
- Asthma
- Diabetes
- Cancer
- Chronic Fatigue / Glandular Fever
- High Blood Pressure
- Low Blood Pressure
- High Cholesterol
- Blood Clots
- Pregnant / Trying to Become Pregnant
- Tuberculosis
- Bronchitis
- Fever
- Hepatitis
- Migraine
- Stomach Ulcer
- Epilepsy
- Obesity
- Arthritis / Joint / Bone problems
- Muscle Problems / Injuries
- Back Pain / Spinal Abnormalities
Other medical details
Any other medical conditions / injuries or major surgeries? Please explain.
Have you ever been told by your doctor to avoid any type of exercise or strenuous activity? If yes, please explain.
If you take prescribed medication which may affect / be affected by physical activity please describe.
Please provide details of medical practitioner who is treating you (if you are happy for us to contact him / her) regarding your exercise program.
Terms & Conditions
- All sessions must be paid for in full before being undertaken. Payments are made fortnightly via direct debit.
- At least 24 hours’ notice is required to cancel a session (for a make-up session to be granted).
- Please bring a water bottle and large towel to each session. Towels are to be used on equipment and mats in gym.
- Please read full list of Terms & Conditions which is provided to all clients in their Introductory Pack
*PREGNANCY: If you become pregnant, please notify EverMotion as soon as possible as special considerations need to be taken. It is also wise to wait at least six weeks after birth before resuming exercise (however, please consult your medical practitioner before resuming).

To the best of my knowledge I have provided all the relevant information that may affect my ability to exercise. I take full responsibility for my actions at all times during workouts with EverMotion and while on the premises. I understand and accept the cancellation policy.
Signature*
Date*
If you have any questions please email us at [email protected] or call 0417 030 751.
CAPTCHA

HEALTH FORM

Emergency Contact Person

Current Exercise

Exercise Goals

Health History

Medical Conditions

Other medical details

Terms & Conditions