Medical Check The following medical check has been designed as a pre-exercise screening tool to determine what levels of exercise you are ready for. Answering the questions as accurately as possible will help us establish any considerations we may need to make in order to make your training experience as safe and enjoyable as possible. All information provided remains confidential.Full Name* First Last Age*D.O.B* DD slash MM slash YYYY Address* Suburb* Post Code* Email* Mobile* WK Phone Emergency ContactName* Relationship* Contact Number* Please answer the following questions and provide additional details where applicable:Do you have or have you ever had any of the following? Any heart condition or heart murmur Hernia Muscular Pain Back or Neck Problems Calf Pain or Swollen Ankles Bone or Joint Problems High Cholesterol Infections or Infectious Diseases Liver or Kidney Condition High Blood Pressure (hypertension) Diabetes Glandular Fever Stroke Epilepsy Asthma Arthritis Osteoporosis Are you pregnant or have you given birth in the last six weeks?* Yes No Are you currently taking any form of medication?* Yes No Have you had surgery in the last two years?* Yes No Do you smoke or have you quit in the last two years?* Yes No Please list any allergies you suffer from:*In the event of a pre-existing health problem such as epilepsy, heart condition, head injury, fractures, spinal problems or any other problematic condition, the participant must obtain a medical certificate from an appropriately qualified medical practitioner confirming that it is safe for the participant to engage in rigorous training activities. For boxing and sparring, all participants over 40 years of age must have a medical certificate provided at their cost certifying that such participant is physically capable to safely undertake the dangerous recreational activity of boxing and sparring. CHILDREN - Children who are 13-14 years of age (inclusive) may become members and have access only whilst they are fully supervised by a personal trainer and / or a parent or legal guardian. Children 15 years of age or older can join as a member (with authorisation of parent or guardian) but may have restricted access to some facilities and services. Parent Initials* EQUIPMENT: For the safety of you and others, please follow all equipment operating and safety instructions on the equipment. If you are not sure of correct use or operation of equipment please seek assistance from a Nitro team member. For the Functional Training Equipment please seek assistance from a Personal Trainer if you are unfamiliar with the equipment or its safe and appropriate use.Consent* I acknowledge that:*• I have read and understood the questions in this form and I have answered the questions honestly to the best of my knowledge and ability. • Any participation in physical activity is not without risks or dangers and my participation is voluntary and informed. • I have not failed to disclose any medical conditions that a suitably qualified medical practitioner would consider may render me unsuitable for rigorous physical activity. I undertake to release to the full extent of the law Studley Fitness PTY LTD trading as Nitro Boxing Fitness Centre along with all employees/agents from all claims, demands and proceedings whatsoever with respect to any accident, incident, loss or injury. SignaturePhoneThis field is for validation purposes and should be left unchanged.
