Blitzfit Chermside Health Form Questionnaire
Health Assessment Questionnaire plus booking into first session
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Let's start with your First and Last name! *
How did you hear about us? Who inspired you to join us at our team? *
Your postal address *
Your mobile number *
Your email address (please check spelling) *
Your birthday (day/month/year) *
Your occupation & company you work for *
Is your job physical or sedentary? *
Have you been a member of a gym or other boot camp before? *
Required
If yes, what did you like about it?
Was there anything you didn't like about it?
How long have you been thinking about starting an exercise program? *
What has kept you from starting sooner? *
Is this still a problem? *
What do you think your current fitness level is? *
Are you currently exercising at the moment? *
If you are currently exercising, what sort of exercise are you doing and how often each week do you do this?
YOUR GOALS!  What do you want to achieve by training with us at boot camp (select all relevant answers): *
Required
When do you want to hit these goals by? *
How important is it to you that you reach your goals? *
Not important at all
Very important
What is your main reason or motivation for wanting to achieve these goals? *
Would you like some information about our personal training packages too? *
Who of your friends/family are supporting you in this exercise program? *
HEALTH ASSESSMENT - Do you suffer from, or have you ever suffered from any of the following: *
Yes
No
Arthritis
Asthma
Diabetes
Epilepsy
Heart Condition
High or low blood pressure
Heart palpitations/chest pain
Any infections or infectious diseases
Back pain
Any major injuries
Females: Have you been pregnant recently
If you answered "Yes" to any of the above questions, please explain condition(s).
If you answered "Yes" to any of the above questions, please advise whether you are cleared by your Dr to exercise.
Clear selection
Do you: *
Yes
No
Smoke
Drink alcohol
Eat 'junk' food
If yes, how much and how often?
YOUR EMERGENCY CONTACT DETAILS - Please type in your emergency contact's full name, mobile number and relationship to you. *
DECLARATION
By ticking the YES box below,  I warrant to Katherine Gorrie that all information provided on this form is true and correct.  I accept that I will not have any claim or any nature against Katherine Gorrie and/or any trainers contracted under her business for any illness, injury or adverse change in medical condition or state of health arising directly or indirectly from any program or advice provided by or carried out preparatory to or as part of any program I undertake whilst under the supervision or instruction of Katherine Gorrie and/or any trainers contracted under her business.  Any rights granted to me by law which are not capable of change by agreement remain unaffected by the terms of this agreement.
By ticking YES, I agree to the above. *
Which option would you like? *
Required
Which session would you like to start with? Please select date & time of first session below, then scroll down to the bottom of the page & hit SUBMIT.
Thank you!  Kath will be in touch within 24 hours to confirm your booking and discuss any injuries/health concerns you may have!
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