Pre Exercise Screening Form

Name *
Date Of Birth *
Date Of Birth
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Please check the box on any condition which you suffer from *
Please confirm that you have read and accepted the below by checking the box: *
General Statement of Program Objectives and procedures: I understand that this personal training program may include exercises to build the cardio respiratory system (heart and lungs), the musculoskeletal system, (which involves muscular endurance, strength and overall flexibility), and to improve body composition (increasing muscle and bone and decreasing body fat) Exercise includes aerobic activities, such as walking, running, bicycle riding, rowing machine, group aerobics, swimming and other aerobic activities, weight lifting using dumbbells, machines and other equipment to improve muscular strength and endurance, as well as flexibility exercises to improve joint range of motion. Nutritional guidelines are set in place to improve body composition, awareness of food intake and needs and overall health. Description of Potential Risks: I understand that the reaction of the heart, lung, blood vessels as well as other systems to exercise cannot always be predicted with accuracy. I know there is a risk of certain abnormal changes occurring during the following exercise, which include abnormalities of blood pressure or heart attacks as well as other side effects. Use of weight lifting equipment, and engaging in heavy body calisthenics may lead to musculoskeletal strains, pain and injury if adequate warm-up, gradual progression, and safety procedures are not consistently followed. I understand that personal trainer (seller) shall not be liable for any damages arising from personal injuries sustained by client (buyer) while and during and/or from a personal training program does so at his/her own risk. Client (buyer) assumes full responsibilities for any injuries or damages which may occur during and/or after training. I also understand that any nutritional guidance is under the assumption that I do not suffer from any medical conditions which would affect said guidance. I understand that nutritional guidance is not a replacement for the advice of a registered nutrition professional such as a dietician. I understand that if I feel unwell as a result of the nutritional guidance or exercise, or a combination of both, I should seek medical advice immediately. I hereby fully and forever release and discharge Bua Fitness, it’s owners, employees, associates, assigns and agents from all claims, demands, damages, rights of action, present and future therein. I understand and warrant, release and agree that I am in good physical condition and that I have no disability, impairment or ailment preventing me from engaging in active or passive exercise that will be detrimental to heart, safety, or comfort, or physical condition if I engage or participate (other than those items fully discussed on the health screening form). I state that I have had a recent physical check up and have my personal physician’s permission to engage in aerobic and/or anaerobic conditioning. Description of Potential Benefits: I understand that a program of regular exercise for the heart, lungs, muscles and joints has many benefits associated with it. These may include a decrease in body fat, improvement in blood fats and blood pressure, improvement in physiological function and decrease in heart disease. I have read the foregoing information and understand it. Any questions, which may have occurred, have been answered to my satisfaction. I warrant that the above I have provided is true and accurate to the best of my knowledge. I undertake to complete a new prescreening form in the event of any change in my medical status during the course of my training. I understand that it is my responsibility to advise Bua Fitness, it's associates and employees of any medical/physical conditions that may prevent me from exercising, and that I participate in exercise at my own risk. Additional information on terms and conditions of service available at