PERSONAL DETAILS
Name *
Name
Date of Birth *
Date of Birth
SCREENING FORM
Please answer YES or NO and detail where necessary
Are you currently taking ANY medication? *
Are you pregnant or have given birth in the last 3 months? *
Is there a history of heart problems or chest pain in your family or with you? *
Do you have HIGH OR LOW blood pressure? *
Do you have difficulty with physical exercise or advice from your GP to avoid specific movements? *
Do you have Diabetes? *
Do you have any muscle, joint or back disorders that could be aggravated by physical exercise?
Have you a recent surgery? (within last 3-6 months?) *
Do you have Asthma or trouble breathing? *
Do you have ANY chronic illness? *
Do you have high blood cholesterol levels?
Do you ever feel faint, dizzy or light-headed?
Do you have any conditions that will prevent you from performing exercises ranging from high impact moves, running, pressing, lifting and an elevated heart rate? *
By signing this you agree that all the information above is correct as of todays date and that if there are any changes to your health you will notify your trainer. You are aware that training of any kind involves risks, and that adequate care, attention and instruction will be given for each specific exercise. If you are ever in doubt about something you hereby agree to communicate clearly in asking for help. *
By signing this you agree that all the information above is correct as of todays date and that if there are any changes to your health you will notify your trainer. You are aware that training of any kind involves risks, and that adequate care, attention and instruction will be given for each specific exercise. If you are ever in doubt about something you hereby agree to communicate clearly in asking for help.
Todays Date *
Todays Date

Thank you for your patience. We very much look forward to helping you move in whichever direction(s) you choose.

Andy Myers
Founding Owner + Head Coach
The Movement Studio