AB. member formPlease complete the form below. Name * First Name Last Name Date of Birth * MM DD YYYY Gender Select Male Female Other Email * Phone * (###) ### #### Pre-Exercise Screening Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke? * Select Yes No Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise? * Select Yes No Do you ever feel faint, dizzy or lose balance during physical activity/exercise? * Select Yes No Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? * Select Yes No If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months? Select Yes No Do you have any other conditions that may require special consideration for you to exercise? * Select Yes No Family history of heart disease (e.g. stroke, heart attack?) If yes, please note Relationship and Age at heart disease event Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months? If yes and are currently smoking, please state how many per day or week Have you been told that you have high blood pressure? If yes, please record systolic/diastolic (mmHg) if known and if taking any medication please list Have you been told that you have high cholesterol/blood lipids? If yes, are you taking any medication for this condition? Have you been told that you have high blood sugar (glucose)? If yes, are you taking any medication for this? Are you currently taking prescribed medication(s) for any condition(s)? These are additional to those already provided. If yes, please list the medical conditions Have you spent time in the hospital (including day admission) for any condition/illness/injury during the last 12 months? If yes, please provide details Are you pregnant or have you given birth within the last 12 months? If yes, please provided details Do you have any diagnosed muscle, bone, tendon, ligament or joint problems that you have been told could be made worse by participating in exercise? If yes, please provide details What are your training goals? * Rate the areas below you would like to improve the most * Strength Strongly Disagree Disagree Neutral Agree Strongly Agree Conditioning Strongly Disagree Disagree Neutral Agree Strongly Agree Mobility Strongly Disagree Disagree Neutral Agree Strongly Agree How many years of experience do you have training in a gym? And what type of training/gym was it? * e.g. CrossFit Gym/Commercial Gym etc. How many days a week do you train? And how long are your sessions? * Thank you!
