O'Malley Fitness Pty. Ltd.

Why do you want to start training with us?
Name:
Address:
Postcode:
Birth date:
Gender:
Phone: AH:
BH:
Mobile:
Email:	Enter your email address
(Emergency contact details)
Name:
Phone: AH:
BH:
Mobile:
Health Screen
	Please select all that apply:
Have you ever had heart trouble?
Do you frequently suffer pains in your heart or chest?
Do you often feel faint or have faint spells or severe dizziness?
Has anyone in your family ever suffered from coronary heart disease?
(If yes, was before the age of 65?)
Are you over 35 and not accustomed to vigorous exercise?
Is your ability to exercise affected by any bone or joint conditions?
Are there any other medical or physical conditions which may limit your ability to exercise?
(If yes, please give further details)

Additional Health Information
	Please select all that apply:
Do you have difficulty breathing?
Heart Palpitations?
High Blood Pressure?
High Cholesterol / Triglyceride?
Diabetes?
Asthma?
Varicose Veins?
Hernia?
Arthritis / Joint Pain?
Epilepsy?
Eating Disorder?
Are you pregnant or attempting to fall pregnant?
Are you using any form of medication? (if yes what is it & dosage information)
Do you smoke?

Please give name and contact details of any health professionals involved
in the treatment of any medical or physical conditions.

If answered yes to any of the above question, please give details.

Declaration

I hereby represent to O’Malley Fitness, its management and employees that I am physically capable of and there is no medical reasons to prevent me from proceeding with the use of the studio/gym premises and any external activities conducted by O’Malley Fitness without endangering my health. I acknowledge that whilst on and off studio/gym premises, my person, my guests, my property, and my guest property are at my own risk. I acknowledge that I will not hold O’Malley Fitness and/or its trainers responsible for and O’Malley Fitness and/or its trainers herby excludes, to the extent permitted by law, all liability for any personal injury or damage (whether direct, indirect, special or consequential) suffered by me or my guest or lost of property by me or my guest while I am on the studio/gym premises or arising in any way out of the Outdoor sessions, use of the facilities and the equipment provided by the studio/gym or trainers, however that injury, damage or loss is caused, including if it is caused by negligence of the studio and/ or its trainers. I acknowledge that except as provided in this document O’Malley Fitness gives no warranties in respect of the facilities and equipment it provides. I hereby release and will indemnified O’Malley Fitness and its trainers for any injury or loss suffered by me whilst on the studio/gym premises or engaged in training sessions conducted externally.

Do you accept these terms? Full name:
Date:

Trainer's Name:

Lifestyle Questionnaire:

Are you currently involved in any form of exercise and/or sport? If yes what type and how many times a week?

What forms of exercise and/or sport have you done in the past?

Are there any forms of exercise that you dislike? What are they?

How many meals a day do you have?
What time do you normally eat?
Breakfast:
Lunch:
Dinner:
When do you snack?
What is the most common meal that you skip?
How many pieces of fruit and veg do you eat a day?
Fruit:
Vegies
Rate your energy levels out of ten (ten being highest)	/ 10
What time do you normally:
Wake up in the morning?
Go to sleep?
How many hours sleep do you have a night?
Rate the quality of your sleep:	/ 10
How many hours a week do you work?	hrs

What are your physical demands of your work?

Do you have any current or past injuries that may affect your ability to exercise?
What are they and how did they occur?

What forms of treatment have you had for these injuries?

Can you rate the extent of pain that you experience
with your injury on a scale of 1 to 10 (10 extreme pain) /10

What assists in relieving the pain?

How does our injury affect your everyday life?

Rate your satisfaction in your current physical state out of 10 (10 being highest) / 10

Why Are You Here?

In a couple of sentences detail why you are here?

List four things you would like to achieve over the next six weeks.

Over the next six months

On a scale of 1 - 10 how important is it you achieve these goals (10 being most important) / 10

What are some potential barriers in achieving these goals?

Can you think of some strategies to overcome these barriers?

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