info@bouncefitnessstudio.in
+91 99958 89946
info@bouncefitnessstudio.in
+91 99958 89946
Bounce Fitness Studio – Member Registration Form
PRE-EXERCISE HEALTH SCREEN QUESTIONNAIRE
(This information is confidential and will be stored with regard to Privacy Issues)
PERSONAL CONTACT DETAILS
First name
Valid first name is required.
Last name
Valid last name is required.
Address
Please enter Address.
Post Code
Please enter Post Code.
Phone Home
Home Phone Number required.
Work
Work Phone Number required.
Mobile
Mobile Number required.
DOB
Please enter Date Of Birth.
Age
Please enter Age.
Occupation
Please enter Occupation.
Email
Please enter a valid email address for shipping updates.
Name of Emergency Contact & Relationship To You
Please enter Contact details.
Emergency Contact Phone Number
Please enter Contact Number.
MEDICAL CONTACT DETAILS
Doctor Name
Please enter Doctor Name.
WARNING: Before embarking on a new program of fitness and exercise, you should consult your doctor. Refer also to our waiver and release from liability for other important information. (The waiver must be read and completed in conjunction with this Pre-screening Health Survey).
Pre-screening Health Form
HEALTH HISTORY STAGE 1:
Please Select Where Indicated And Provide Other Details As Appropriate
Are you male over 45 or female over 55 years & NOT used to regular, moderate intensity exercise?
Choose...
Yes
No
Please select a valid Option.
Have you been advised by your doctor not to exercise?
Choose...
Yes
No
Please select a valid Option.
Have your parents or siblings had a heart attack, suffered from cardiovascular/ heart disease, stroke, raised cholesterol or sudden death before 65 years old?
Choose...
Yes
No
Please select a valid Option.
Do you have diabetes?
Choose...
Yes
No
Please select a valid Option.
Have you had a stroke?
Choose...
Yes
No
Please select a valid Option.
Do you take Astha medication?
Choose...
Yes
No
Please select a valid Option.
Do have difficulty breathing due to Bronchitis or Emphysema?
Choose...
Yes
No
Please select a valid Option.
Has your doctor ever said that you have heart trouble/heart disease?
Choose...
Yes
No
Please select a valid Option.
Are you pregnant or given birth in the last 6 weeks?
Choose...
Yes
No
Please select a valid Option.
Has your doctor told you that you have high blood pressure ?
Choose...
Yes
No
Please select a valid Option.
Do you have any pains or palpitations in the chest, heart, or surrounding areas, especially during exercise?
Choose...
Yes
No
Please select a valid Option.
Do you feel a faint or severe dizziness during exercise?
Choose...
Yes
No
Please select a valid Option.
Do you experience unusual fatigue, shortness of breath at rest or with mild exertion?
Choose...
Yes
No
Please select a valid Option.
Have you been awakened at night by an attack of shortness of breath or had an attack of shortness of breath following exercise?
Choose...
Yes
No
Please select a valid Option.
Do you get the feeling that your heart is beating faster, racing or skipping beats either at rest or during exercise?
Choose...
Yes
No
Please select a valid Option.
Do you get pain in your calves or lower legs during exercise which is not due to stiffness or soreness?
Choose...
Yes
No
Please select a valid Option.
Do any of the following health conditions apply to you? (Please select the ones that applies to you?
Epilepsy
Hernia
Infections or Infectious Diseases
Glandular Fever
Rheumatic Fever
Liver or Kidney condition
Stomach or Duodenal Ulcer
Cancer
If you have selected any of the above, please obtain a medical clearance from your doctor to exercise.
Have you been hospitalised recently?
Choose...
Yes
No
Please select a valid Option.
Date
Select Last Hospitalized Date.
Any operations within the last 12 months?
Choose...
Yes
No
Please select a valid Option.
Date
Select Last Hospitalized Date.
If you have selected any of the above, please obtain a medical clearance from your doctor to exercise.
MEDICAL CLEARANCE TO EXERCISE
This process involves asking your doctor:
1. For clearance to begin an exercise regime.
2. What activities may you safely participate in.
3. What specific restrictions, if any, should apply to your condition and which activities and/or exercised should you avoid.
4. Any activities that your doctor would particularly recommend to assist your particular condition.
5. Identify when to exercise in relation to any medication currently being prescribed.
Please tick here if you have already cleared the above conditions with your doctor.
HEALTH HISTORY STAGE 2
Please Select Where Indicated And Provide Other Details As Apropriate
Do you smoke cigarettes?
Choose...
Yes
No
Please select a valid Option.
Did you smoke in the past?
Choose...
Yes
No
Please select a valid Option.
when did you give up?
Enter Details.
Do you have Gout, Osteoarthritis, Rheumatoid Arthritis, Ross Liver, Fibromyalgia, SLE or other forms of arthritis?
Choose...
Yes
No
Please select a valid Option.
Do you suffer from allergies and require an epipen?
Choose...
Yes
No
Please select a valid Option.
Do you have a pacemaker?
Choose...
Yes
No
Please select a valid Option.
If you have selected any of the above, please obtain a medical clearance from your doctor to exercise.
INJURY HISTORY
Please Select And Provide Details Wherever Applicable
Have you ever had injury, surgery or joint replacement to your:
Ankle?
Knee?(torn ligament or cartilage)
Shoulder?
Neck? (such as whiplash)
Back/Spinal disc injury?
Elbows?
Wrist?
Other?
EXERCISE HISTORY
What are your current activity patterns?
Frequency (What are your current activity patterns?)
Duration (Minutes per session)
Intensity (select one)
Sedentary
Moderate
Vigorous
History (select one)
Less than 3 Months
3-12 Months
More than 12 Months
Do you want to exercise at a moderate intensity (eg. Brisk walk) or at a vigorous intensity (eg. Jogging) – Select one from below.
Moderate
Vigorous
Why am I here today? What level of change in my health, body and lifestyle do I want in a 6-12 month time frame?
Please enter Details.
GYM HYGIENE
Changing to gym footwear a must.
Please make sure that you change into your gym footwear only upon arrival at the gym. Street shoes are not entertained inside the gym for pure sanitation and hygiene purpose.
Wipe the equipment before and after use.
Bring a pack of wipes or a separate hand towel just for wiping the equipment or exercise mat before and after use.
Bring your own.
If you have sensitive skin or are prone to getting sick, consider bringing your own mat or at least a long towel to use over the mat.
When sick, please try to stay home and recover well.
REFUND POLICY
Kindly note that we follow a ‘NO REFUND’ policy for payments once made.
Generate OTP
Enter OTP
Save
