HEALTH SCREEN

Your Goal

Full Name*

First NameLast Name

Birth Date*

MonthDayYear

E-mail*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Instagram

If you are on Instagram what is your Instagram handle (name)

Phone*

Gender

Trainers Name*

Why Are You Here ?

Other

Select all that apply

Have you ever had heart trouble?Do you suffer pains in your heart or chest?Do you often feel faint or severe dizziness?Has anyone in your family suffered from coronary heart disease?If yes above - was it before the age of 65?Are you over 35 and not accustomed to vigorous exercise?Is your ability to exercise affected by any bone or joint conditions?Are there any other medical or physical conditions that may limit your ability to exercise?

If yes - please provide details

Do you have....

If yes to any of the above, please provide details

Name and contact of health professionals involved in your treatment

I hereby represent to O’Malley Fitness, its management and employees that I am physically capable of, and there are no medical reasons to prevent me from proceeding with the use of the studio/gym premises and any external activities conducted by O’Malley Fitness without endangering my health.

I acknowledge that while on and off studio/gym premises, my person, my guests, my property, and my guest property are at my risk. I acknowledge that I will not hold O’Malley Fitness and/or its trainers responsible for and O’Malley Fitness and/or its trainers hereby excludes, to the extent permitted by law, all liability for any personal injury or damage (whether direct, indirect, special or consequential) suffered by me or my guest or loss of property by me or my guest while I am on the studio/gym premises or arising in any way out of the Outdoor sessions, use of the facilities and the equipment provided by the studio/gym or trainers, however that injury, damage or loss is caused, including if it is caused by negligence of the studio and/ or its trainers.

I acknowledge that except as provided in this document O’Malley Fitness gives no warranties in respect of the facilities and equipment it provides.

I hereby release and will indemnify O’Malley Fitness and its trainers for any injury or loss suffered by me while on the studio/gym premises or engaged in training sessions conducted externally.

Do you accept these terms*

YesNo

Are you currently involved in any form of exercise and/or sport? If yes what type and how many times per week

What forms of exercise and/or sport have you done in the past?

Are there any forms of exercise that you dislike? What are they?

How many meals a day do you eat?

What time do you normally eat breakfast, lunch & dinner?

When do you snack?

What is the most common meal that you skip?

How many pieces of fruit do you eat a day?

How many seves of vegetables do you eat a day?

Rate your energy levels out of 10 (10 being highest)

What time do you normally wake in the morning?

What time do you normally go to sleep?

How many hours of sleep do you have a night?

Rate the quality of your sleep

How many hours a week do you work?

What are the physical demands of your work?

List any current or past injuries that may affect your ability to exercise

If any injuries listed how did they occur

What form of treatment have you had for these injuries?

Rate the extent of your pain of these injuries (10 being extreme pain)

What assists in relieving the pain?

How does your injury affect your everyday life?

Rate your satisfaction of your current physical state out of 10 (10 being the highest)

List 4 things you would like to achieve over the next 6 weeks

List 4 things you would like to achieve over the next 6 months

On a scale of 1 - 10 how important is it you achieve these goals (10 being extremely important)

What are some potential barriers in achieving these goals?

Can you think of some strategies to overcome these barriers?

Please run the wizard

O’Malley Fitness may upload photos and video of you training that could include your image to our Facebook page & our website. FACEBOOK: O’Malley Fitness WEBSITE: www.omalleyfitness.com.au Please us advise us in writing if you do not provide your consent. We are very active on FACEBOOK and INSTAGRAM- Likes us @omalleyfitness

Health Screen

Declaration

Lifestyle Questionnaire