PRE-EXERCISE/LIFESTYLE

SCREENING QUESTIONNAIRE
Name: ______________________________________ DOB: ___/___/___ Age: _____ Sex: M / F
E-mail:__________________________________@_____________________________________
Address:_______________________________________________________________________
Primary Phone:___________________________ Secondary Phone: _______________________
Occupation: _________________________________ Have you used a gym before?

Y/N

Emergency Contact Name: ___________________________________Ph: ___________________

Part A: Medical Considerations

It is our professional duty of care to ask all participants, no matter what age, to complete
the following questions: (Simply place a to indicate Yes)

NOT used to regular vigorous exercise? __

Do you have or have you had:

Gout ___

Glandular Fever ___

Any Heart condition ___

Stroke ___

Rheumatic Fever ___

Heart Murmur ___

Dizziness or Fainting ___

High Blood Pressure (over 140/90) ___

Diabetes ___

Epilepsy ___

Raised Cholesterol/Triglycerides ___

Arthritis ___

Hernia ___

Chest Palpitations / Pains ___

Muscular Pain ___

Asthma ___

Stomach/Duodenal Ulcer ___

Cramps ___

Liver or Kidney Condition ___

Do you have any Pain or Major Injuries in the following areas:

Neck ___

Knees ___

Back ___

Ankles ___

PRE-EXERCISE/LIFESTYLE
SCREENING QUESTIONNAIRE
Please give details of any conditions:

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
If you have ticked any of the above, you need a signed medical clearance from your doctor before
starting exercise.
Doctors clearance: _______________________________________ Date: ___/___/___
Or: I warrant that I am physically and mentally well enough to proceed with usage of the
facility.
Clients self clearance of the above conditions: __________________ Date: ___/___/___

Part B: Lifestyle and current exercise habits

Are you currently exercising regularly? Yes ___ No ___
If yes, please give details below:

Do you smoke? Yes _ No _

If yes, how many per day?

Type of exercise:
1 5 _ 6 10 _ 11 15 _ 16 20 _ 21 - 25 _ 25+ _
___________________________________________
___________________________________________
Frequency of exercise (times per week):

Are you allergic to anything? Y___ N___

1 _ 2 3 _ 3 4 _ 5+ _

If yes, please list:

___________________________________________

Perceived intensity when exercising:

Hard _ Medium _ Light _ V Light _

Part C. Please () what you hope to achieve

To reduce body fat __

To generally tone up __

To improve aerobic capacity (heart/lung fitness) __

To gain strength __

To gain some muscle definition __

Other ____________________________________

To gain overall fitness __

Additional information:
________________________________________________________________________________________
________________________________________________________________________________________

PRE-EXERCISE/LIFESTYLE
SCREENING QUESTIONNAIRE
Please read the following statement carefully.
I recognise that the instructor is not able to provide me with medical advice with regard to my fitness, and that
this information is used as a guideline to the limitations of my ability to exercise. I have answered questions to
the best of my ability and understand the advice above.
Signed: ________________________________________________ Date: ___/___/___
WHERE PARTICIPANT IS UNDER 18 YEARS OF AGE
I __________________________________ being the parent or guardian of the person named in this
acknowledgment and release
HEREBY ACKNOWLEDGE AND AGREE:
I have read the whole document and understand it.
I consent to the person named in this acknowledge and release participating in the activity and
I am aware of the risks, dangers and obligations set out in this acknowledgment and release.
IN CONSIDERATION of the person named in this Acknowledgment and Release being accepted to participate in
the activity I AGREE TO RELEASE AND INDEMNIFY the Fitness Centre Operator in the same manner and to
the same effect as if I were the person first named in this Acknowledgment and Release and the person
participating in the activity.
SIGNATURE OF PARENT/GUARDIAN: _________________________________ DATE: ___/___/___

OFFICE USE ONLY

Comments:________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Instructor name: ______________________________ Date: ___/___/___ Time:________________

Rules and Waiver

Welcome to CrossFit 4820, to get started, it is important that we set some basic gym rules. We enjoy the
social nature that our workouts promote and dont wish to spoil it, however our primary focus will always
be on quality training and we need your support for that to continue.
Be on time:
Please be present and ready to start the warm-up at the designated start time. It is important that you
are there on time in order to receive the necessary information for the WOD and to participate in the
entire warm-up. Furthermore, plan to stay for the entire session. Aside from stretching, the end of the
session is a time where coaching points can be reviewed and general information can be relayed.
Penalties apply.
Initials: _____________
Dont talk when instructions are being given:
We dont believe that anyone that is talking is being intentionally rude, but it happens quite a lot. When a
trainer is giving instructions please cease your chat. The movements we perform are technical at times
and large loads are often moved. If you are not aware of a critical instruction due to inattention, you are
more likely to injure yourself or someone else. Please feel free to ask questions during the Do you have
any questions? section of the brief.
Initials: _____________
Encourage without Coaching:
We encourage you to support your fellow athletes with "c'mon, one more rep!" and we love to see people
finish their workout and give support to those that are still slugging it out! We know that members have
good intentions when they start giving coaching cues, but there is a big difference between cmon one
more rep and you need to... <insert coachingadvice>. This may offend the person that is doing the
workout, or provide misinformation on the technique. If you see something that looks unsafe, grab a
coach, thats what we are here for.
Initials: _____________

Be Responsible For Your Own Fitness:

Scaling back a workout when necessary is intelligent, not weak. You cannot get fitter by staring at a bar
that is too heavy. People enter the gym with predisposed ideas of what weights they should be lifting or
try to match somebody else. Our aim is to ensure youre perfecting the movement first, and then increase
the intensity. We ask all members to respect our judgment we are not trying to hold you back, we just
want you to progress in the most safe and efficient way.
Initials: _____________

Rules and Wavier

Injuries:
Everyone gets a little niggle at some point, so if you do have an injury we want to know about it, however
minor it may seem. That way we can help design a specific rehab program, or refer you to the relevant
health professional. It also allows us to adjust your session so that were not putting additional strain on
your injury.
Initials: _____________

Always put equipment back at the end of a class

Every piece of equipment has its own special little place in the gym. If you take it out of that place make
sure you wipe it over then put it back when youre finished. A place for everything and everything in its
place!
Initials: _____________

No kids in the gym during sessions please:

We feel our workout group has a great community, and many of you have children. If you have no other
alternative please ensure that you have a suitable minder for your children and that they stay out of the
shed and away from athletes performing workouts. We just dont want kids at risk from getting whipped
by skipping ropes, or getting hit by dropping kettlebells, and rolling barbells. Please do not allow your kids
to play on the equipment. Keep your kids safe, and ensure that the kids are under capable supervision
at all times. Thanking you in advance.
Initials: _____________

Make everyone feel at home

One of the best things about our workout sessions is the fact that we perform them together, as a team.
We will not tolerate anyone being unfriendly to any of our members. We expect everyone to feel
welcome and comfortable at our sessions.
Initials: _____________

Wavier
In consideration of CrossFit 4820 allowing me to participate, I acknowledge, understand and I am aware
that:
I have voluntarily chosen to participate in training activities provided by CrossFit 4820. I understand
there are inherent risks in all aspects of physical training and I acknowledge that I have been informed of
the possible strenuous nature of the training and the potential for undesirable physiological results
including, but not limited to, abnormal blood pressure, muscle soreness, fainting, heart attack and/or
5

Rules and Waiver

death. I also acknowledge that I have been specifically warned about the medical condition
Rhabdomyolysis and accordingly I have been advised to limit my effort in order to minimise the risks
associated with this condition. Initials: _____________

I understand that the training may involve weightlifting, gymnastic movements, strenuous bodyweight
exercises and other high exertion activities, and that I am not obligated to perform nor participate in any
activity that I do not wish to do, and that it is my right to refuse such participation at any time during my
training sessions. I understand that should I feel lightheaded, faint, dizzy, nauseated, or experience pain or
discomfort, I am to stop the activity and inform my trainer. I give CrossFit 4820 and the organisers of the
facilities I train in permission to seek emergency medical services for me should I become injured or ill
with the understanding that I am responsible for any expenses incurred.
Initials: _____________

I agree to WAIVE ANY AND ALL CLAIMS that I have or may have in the future against CrossFit 4820, and
its owners, trainers, employees, agents, volunteers and independent contractors (all of whom are
hereinafter collectively referred to as the Releasees). I agree to RELEASE THE RELEASEES from any and
all liability for any loss, damage, injury or expense that I may suffer, or that my next of kin may suffer as a
result of my participation in the programs, activities and services provided by CrossFit 4820 , due to any
cause whatsoever including negligence, breach of contract, or breach of any statutory or other duty of
care. I agree to HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any
damage to the property of, or personal injury to, any third party, resulting from my participation in any
program, activity or service provided by the releasees. Initials: _____________

This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or
transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement
shall remain in full legal force and effect. If I am signing on behalf of a minor child, I also give full
permission for any person connected with CrossFit 4820 to administer first aid deemed necessary, and in
case of serious illness or injury, I give permission to call for medical and or surgical care for the child and to
transport the child to a medical facility deemed necessary for the wellbeing of the child.
Initials: _____________

Use of picture(s)/film/likeness: I agree to allow CrossFit 4820 its agents, officers, principals, employees
and volunteers to use picture(s), film and/or likeness of me for advertising purposes. In the event I choose
not to allow the use of the same for said purpose, I agree that I must inform CrossFit 4820 of this in
writing. Initials:_____________

Waiver
I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS
INFORMED CONSENT FORM I AM WAIVING CERTAIN LEGAL RIGHTS (INCLUDING THE RIGHT TO SUE)
WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTOR, ADMINISTERS AND ASSIGNS MAY HAVE AGAINST THE
RELEASEES. ANY QUESTIONS I HAD WERE ANSWERED TO MY FULL SATISFACTION.

Signature of participant: __________________________Date: _______________________

If the participant is under the age of 18,

Signature of Parent or Guardian: ______________________ Date: ___________________

(Parent/Guardian) Print Name: _________________________