This form will be used to gather important information that your trainer will need to know prior to the commencement of your first program. This information will be stored in a secure location, and not released without your written consent.
By completing the following form, you agree that all information provided is correct to the best of your knowledge. You acknowledge that ExMed practitioners require a correct medical & exercise history, in conjunction with additional information provided, to properly determine your suitability to exercise and any potential risks that warrant consideration under our guidance.
Yes, I agree
No, I don't agree
Date of Birth:
What do you currently do for work?
Emergency Contact (Full Name)
Emergency Contact Number
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