Pre-Exercise Form

This pre-exercise form must be completed and submitted before anybody can commence exercise activities with Exercise Unlocked.

* Indicates required field

Name *

First

Last

Phone Number *

Address *

Email *

Date of Birth *

Occupation *

Has your doctor or surgeon ever told you that you have a heart condition or have you ever suffered a stroke? *

If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months? *

Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? *

Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? *

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? *

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? *

Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise? *

Please feel free to leave a message for us *

This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Global Exercise Unlocked Pty for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool or participation in exercise activities administered by Global Exercise Unlocked Pty including it's Directors, employees and contractors. Photographs and videos are sometimes taken at classes for promotional purposes.

I have read, understood and agree with the above statement and believe that to the best of my knowledge, all of the information I have supplied within this form is correct.

Name *

First

Last

Date *

Submit