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Essence Fitness
More than just a 24hr Gym
1 Bay Road, Claremont WA 6010
(08) 9386 8588
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2 Week Trial just $10
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2 Week Trial just $10
2 week trial
Step 1 of 3 - Personal Details
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PERSONAL DETAILS
All questions marked * below are mandatory, please fill them all out.
Name
*
Phone
*
Email
*
MEDICAL DETAILS
All questions marked * below are mandatory, please fill them all out.
Has your doctor ever told you that you have high blood pressure or a heart condition, or have you ever suffered a stroke?
*
Yes
No
As you answered YES to the question above, please provide more detail
*
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
*
Yes
No
As you answered YES to the question above, please provide more detail
*
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
*
Yes
No
As you answered YES to the question above, please provide more detail
*
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
*
Yes
No
As you answered YES to the question above, please provide more detail
*
If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
*
Yes
No
As you answered YES to the question above, please provide more detail
*
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?
*
Yes
No
As you answered YES to the question above, please provide more detail
*
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
*
Yes
No
As you answered YES to the question above, please provide more detail
*
Do you have any allergies
*
Yes
No
As you answered YES to the question above, please provide more detail
Do you or have you had cancer
*
Yes
No
As you answered YES to the question above, please provide more detail
Have you recently undergone any surgery
*
Yes
No
As you answered YES to the question above, please provide more detail
FINAL STEPS
All questions marked * below are mandatory, please fill them all out.
I believe that to the best of my knowledge, all of the information I have supplied within this form is correct.
*
Yes
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