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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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Exercise Program Questionnaire
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Exercise Program Questionnaire
Exercise Program Questionnaire
Step 1 of 4 - Personal Details
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PERSONAL DETAILS
All questions marked * below are mandatory, please fill them all out.
Name
*
Email
*
Date of Birth
*
Please enter a date in the format (dd-mm-yyyy)
Date Format: DD dash MM dash YYYY
Gender
*
Male
Female
Membership Type
*
Standard Membership
Student Membership
Pensioner Membership
Upfront Annual
MEDICAL DETAILS
All questions marked * below are mandatory, please fill them all out.
Has your doctor ever told you that you have 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
*
LIFESTYLE INFORMATION
All questions marked * below are mandatory, please fill them all out.
To get the most out of your membership we highly recommend you book an Individual Personal Assessment. This will comprise of two sessions with a trainer who will analysis your current level of fitness, discuss your goals & targets, and design a personalised program for you to follow. The cost for this will be $85 and will be added to your first direct debit payment.
*
Yes
No
Are you interested in Personal Training sessions?
*
Yes
No
Are you training for a specific sport or event?
*
Yes
No
As you are training for a specific sport or event, please specify:
*
Do you have any exercise dislikes?
*
Yes
No
Please specify the exercises you dislike:
*
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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