pre-exercise screen

Health Questionnaire

Title: (Mr / Mrs / Miss / Ms) Gender: Date of Birth: (dd/mm/yyyy)

First Name: Middle Name: (or other alias) Last Name / Family Name:

Address:

Suburb: State: Postcode:

Email: Mobile No:

How did you hear about us?

Friends & Family Local Google Signage Social Media Other Source _____________________

Nominate a friend to train with you for 7 days

Friend's Name: _______________________________________________ Phone No: _______________________________________________

exercise & health goals

Interests

X2166 Gym Premium Gym Primal Fitness X-Hybrid Canley Heights

What would you like to achieve?

Weight Loss Reduce Body Fat Muscle Tone Strength Cardiovascular

Health Rehabilitation Sport Conditioning Flexibility Other

How much gym/training experience do you have?

None Some Moderate Advanced

Are you interested in any of these additional services?

Personal Training Chiropractic Physiotherapy Remedial Massage

conditions of entry
When using the facility, I understand that I must:

1. Conduct myself in a respectful and responsible manner;

2. Wear enclosed shoes;
3. Use my own towel when using equipment;
4. Not bring my bag onto the gym floor or workout areas;
5. Not take any photos or recordings of other patrons; and
6. Abide by the Conditions of Entry displayed throughout the facility.

If I do not comply with those conditions, staff have the right to ask me to leave the facility until I comply with the conditions.

acknowledgement & release

1. I acknowledge that I completed this Pre-Exercise Screen accurately and in full, and that all the information that I have provided is true.
2. I have read and understood the Terms and Conditions of use.
3. Upon acceptance of my payment for participating in any activity;
i. I participate in all activities at X2166 Training Centre at my own sole risk and responsibility.
ii. I release and indemnify X2166 Training Centre and all its partners, staff, and agents, from and against all and any actions or claims which may be
made by me, on my behalf or by other parties for or in respect or arising out of injury, loss, damage or death caused to me or my property whether
by negligence, breach of agreement or in any way whatsoever.
iii. I agree that I will be responsible for any damage which myself or my guest may cause at the facility, if the damage was caused by my wilful act of
negligence.
iv. I further agree that in the event that I am injured or my property is lost, stolen or damaged, I will bring no legal claim or otherwise, against X2166
Training Centre or its partners, staff, servants and agents, in respect to the injury, loss or damage.

Signed: (parent/guardian signature for members under 16) Date:

medical considerations
If you have or ever had any of the below medical illnesses or conditions, please specify below:
Stroke Heart Murmur Diabetes High Blood Pressure Any Heart Conditions
> 140/90
Palpitations or Gave birth in the Pregnant Other _______________________________
Chest Pains last 6 weeks

If you have specified any medical illness or conditions above, please take this form to a Doctor and ask for clearance to exercise before
commencing any exercise program.

doctor's use only (Or a Doctor's Certificate has been provided and is attached)

Conditions cleared:

Name: Contact number:

Signed: Date:

medical history
If you have or ever had any of the below medical conditions, please specify below:

Gout Glandular Fever Rheumatic Fever Stomach Ulcer Duodenal Ulcer

Hernia Other _______________________________

If you are on any prescribed medication, please specify: If you have specified any illness above, it is strongly advised to ask an
instructor for exercise guidance before commencing exercise.

illness & injuries

If you have any of the below illnesses or injuries, please specify below:

Raised cholesterol Triglycerides Cramps Arthritis Asthma

Muscular Pain Neck Knees Back Ankle

Other ______________________________________________________________________________________________________________

If you have specified any illnesses or injuries above, it is strongly advised to ask an instructor for exercise guidelines before commencing
exercise.

emergency contact If there is an emergency, specify the person who should be contacted

Name: Contact Number: Relationship:

Home Phone: Work Phone:

health statement
I recognise that staff are not able to provide me (or my child) with medical advice in regards to my (or my child’s) medical condition and that
this information is used as a guidance to the limitations of my (or my child’s) ability to exercise.

I will inform staff if I (or my child) suffer any injury, illness or conditions in the future, and I will complete the Pre-Exercise Screen again. I have
answered the questions to the best of my ability and understood the advice above.

Signed: (parent/guardian signature for members under 16) Date:

L 2 & 3, 239 Canley Vale Rd, Canley Heights NSW 2166

P: (02) 9755 9993 W: x2166.com.au E: reception@x2166.com.au ABN: 79 633 051 117