Pre-Exercise Screening Form

Please fill out the following form.

First name

Last name

Email

Date of birth

Day

Month

Year

How would you rate your current fitness level?

Have you been hospitalised in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

Do you experience any dizziness or fainting when exercising?

No

Yes

Are you currently pregnant, breastfeeding or less than 12 months postpartum?

No

Yes

Not Applicable

If you answered yes to any of the questions above, please supply additional information.

I give permission for my photo, video or recording content to be used for promotional or marketing purposes by Ash Hendriks Personal Training.

I declare that the info I’ve provided is accurate and complete.

Signature

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