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PERFORMANCE AND REHABILITATION
PT Enquiry Form
Contact
membership enquiries: 0429 143 972
Operations: team@ifp.com.au
Bens Blog
Community Day Sign-Up
Book Your Free Session for Saturday the 24th of June (Community Day)
Preferred Time
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Pick a time
8am
9am
10am
11am
Name
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MEDICAL CLEARANCE
This information is necessary for your program design. We understand this information is personal and you have our assurance all information provided will be kept confidential.
Have you or a blood relative (under 55) suffered from heart disease, stroke, elevated cholesterol or sudden death?
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Yes
No
Do you have high blood pressure?
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Yes
No
Are you a smoker?
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Yes
No
Do you suffer from high cholesterol?
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Yes
No
Do you have or have you suffered from diabetes? (TYPE 1 / TYPE 2)
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Yes
No
Are you currently on prescribed medication?
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Yes
No
If yes, will this affect your exercise program?
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Yes
No
Are you pregnant or have you given birth in the last 6-weeks?
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Yes
No
Have you had any major injuries involving your Neck, Hips, Back, Knees, Shoulders, Ankles?
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Yes
No
Do you have or have you suffered from Epilepsy, Arthritis, Hernia, Asthma, Dizziness/Fainting?
*
Yes
No
Other
Members are to seek medical clearance before participating in an exercise program if risk factors are present
Health & Fitness Objectives
Please indicate what you are looking to achieve from your training time with IFP:
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Weight Loss
Strength Training
Cardiovascular Fitness
Stress Relief / Improve Self Esteem
Relief/Improve self-esteem
Sports Conditioning
Rehabilitation
Flexibility
How would you describe your current condition?
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Poor
Average
Good
Very Good
Excellent
Have you/do you play any sports?
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Have you had any Personal Training before?
Consent
*
I hereby agree that all the information on this form is accurate to the best of my knowledge.
Date
DD slash MM slash YYYY