First Name *

Last Name *

Email *

Phone *

Address *

Emergency Contact Name *

Emergency Contact Relationship to you *

Emergency Contact Number *

Did someone refer you? Let us know who it was: *

Have you done Crossfit before? *

Yes

If yes, where and how long ago?

Are you a member of a gym? *

Yes

If yes, where and how long ago?

Please choose your current physical activity/exercise levels: *

Sedentary

Light

Moderate

Vigorous

Do you have (or have had), or been told by a doctor that you any of the following conditions?Please tick all boxes applicable to you:

Asthma: Have you had an asthma attack in the last 12-mths that has required immediate medical attention?

Diabetes (Type I or Type II): If you have Diabetes, have you had trouble controlling your blood sugars in the last 3-months?

High Blood Pressure: If you have High BP, have you had trouble controlling your blood sugars in the last 3-months?

Heart Condition: Has a doctor ever told you that you have a heart condition?

Kidney Condition: Has a doctor ever told you that you have a kidney condition?

Fainting/Dizzy Spells: Do you ever feel faint or have dizzy spells while exercising that causes you to lose balance?

Stroke: Has a doctor ever told you that you have suffered a stroke?

Muscle/Bone/Joint Condition: Do you have any diagnosed muscle/bone/joint conditions that may be made worse by exercising?

Other: Do you have any other medical condition(s) that may make it dangerous for you to do exercise or physical activity?

If you answered yes to any of the above, please explain here:

Are you taking any medications for any medical conditions? *

Yes

If yes please list

Do you smoke cigarettes? *

Yes

If yes, how many cigarettes do you smoke per week?

Are you pregnant or have given birth in the last 12-months? *

Yes

Have you spent time in hospital for any medical condition/illness/injury in the last 12 months? *

Yes

If yes, provide details:

HEALTH PRE-SCREEN DECLARATION

declare that I have filled this health pre-screen out to best of my ability with the current knowledge and information that I have regarding my health, medical and fitness levels. I have not knowingly withheld medical information that may cause harm to myself or others while I exercise at Wiki Workz Fitness.

Signature *

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Date of birth *

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