pre activity questionnaire

To register to train please fill out the following medical form

First Name

Email Address

Last Name

Date of Birth

Emergency Contact Details

Has your doctor told you (within the last 6 months) that you should not participate in physical activity? *

Yes

Have you lost your consciousness in the last 12 months? *

Yes

Initials

Phone

Today's Date

Address

I declare that the info I’ve provided is accurate & complete

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes

Do you suffer from regular chest pains?

Yes

In the past month, have you had a chest pain when you were not doing physical activity?

Yes

Do you lose balance because of dizziness or do you ever lose consciousness?

Yes

Have you had any long standing injuries, or do you have any current injuries which will be affected by doing any form of physical exercise?

Yes

Is your doctor currently prescribing medication for your blood pressure or heart condition?

Yes

Do you know of any other reason why you should not take part in physical activity?

Yes

If YES to any of the above, please give details below:

Have you recently tested positive for COVID-19? Do you have any current coronavirus symptoms? Please give details.

If you answered YES to one or more questions:

By filling in this form and by signing the below, I confirm that I am able to participate in physical activity with Tom Sullivan as my personal trainer. I take full responsibility for my participation in training sessions which may include strenuous excercise. I accept liability for any injuries or illnesses which may occur during or as a result of training with Tom Sullivan

Your Signature

Thanks for submitting!

HT Performance Coaching

Subscribe Form

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htperformancecoaching@outlook.com

07539206003

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