CORPORATE TRAINING NEW MEMBER FORM Complete Online Form Here. COMPLETE YOUR REGISTRATION BY FILLING OUT THE PRE EXERCISE SCREENING FORM BELOW. IF YOU HAVE ATTENDED A PREVIOUS TERM, YOU WILL STILL NEED TO COMPLETE THIS FORM. Client DetailsFirst NameLast NameDate of BirthAgeMobileEmailStreet AddressCityStatePostcodeHow did you hear about AMS?How did you find out about Active Movement Studio?How did you find out about Active Movement Studio?GoogleFacebookInstagramFlyerPromotionReferralParramatta CouncilEventbriteOtherMedical/Injury History & MedicationHave you ever been diagnosed with any of the following conditions? Heart condition (angina, stent, pacemaker) Coronary heart disease Heart murmur Stroke or transient ischemic attack Hypotension or hypertension Lung conditions (asthma, emphysema, bronchitis) Chronic obstructive pulmonary disease (COPD) Type 1 or 2 diabetes Metabolic syndrome or insulin resistance High cholesterol (dyslipidaemia) Rheumatic fever Cancer (breast, colon) Arthritis (rheumatoid, osteo, gout) Osteoporosis or ostepenia Stomach or duodenal ulcer Hernia (inguinal, umbilicus, hiatus) Pregnancy Elilepsy Depression anxiety Parkinson's disease Multiple sclerosis Motor neuron disease Frozen shoulder Neck, shoulder, back or knee pain Other, please specific below Other, please specify...Has your doctor ever diagnosed you with a heart or lung condition? If so, have you attempted a rehabilitation program?*SelectYESNODo you experience any unexplained pains in your chest at rest or during physical activity/exercise?*SelectYESNODo you experience any unexplained pains in your chest at rest or during physical activity/exercise?*SelectYESNODo you have low or high blood pressure? If either, are you currently medicated to manage your blood pressure?*SelectYESNODo you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?*SelectYESNOHave you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*SelectYESNODo you get unusually short of breath when engaging in any physical activity/exercise?*SelectYESNOIf you have diabetes (type 1 or 2) have you had trouble controlling your blood glucose in the last 3 months?*SelectYESNODo you have any diagnosed muscle, bone or joint problems? Do any of these conditions cause you pain?*SelectYESNODo you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise?*SelectYESNOHave you been involved in any traumatic event where you sustained an injury that required medical attention?*SelectYESNOMedicationAre you currently taking any prescription medications?YES - complete list belowNOList of medicationsName of MedicationDoseReason for Prescription Exercise HistoryAre you currently engaging in regular structured exercise?AnswerYES - please list belowNOList your current weekly exercise regimeType of exerciseFrequency/weekDuration List any exercise dislikesIn general, how would you rate your current health? 1 = worst & 10 = best 1 2 3 4 5 6 7 8 9 10 WorkWhat is your current occupation?How many hours per day do you spend seated? 0 - 2 2 - 4 4 - 6 6 - 8 Goals & OutcomesExamples of some functional goals you could aim for: Lose 5kg in one month Run 5km without stopping Decrease body fat percentage by 5% Be able to squat my body weight Complete an unassisted chin up Be able to touch my toes Perform a push up on toes Complete 10 Burpees without stopping Goal Setting (set up to 3 goals per category)Immediate (>1 week)Short Term (<3 months)Long Term (>6 months) Patient Information & ConsentInformed Patient Consent* Select All I hereby acknowledge that all the information I have provided to Active Movement Studio is accurate to the best of my knowledge. If unsure of any information I will inform my practitioner. I understand that I may require medical clearance from my general practitioner to determine my suitability to commencing a regular exercise program. As a participant of Active Movement Studio it is my responsibility to notify my trainer if there are any changes to my medical condition including changes in medication. I understand that engaging in regular physical activity can cause potential risk of injury or bodily harm and I will not hold the staff of Active Movement Studio liable if this occurs Privacy Policy* Active Movement Studio is committed to ensuring that all personal information that is disclosed in consultations and sessions will remain confidential and only be accessible by appropriate staff. All personal information is stored in a secure location protected from unauthorized access, modification or disclosure. All staff are regularly reminded of the importance of this matter and any breach in privacy is not tolerated. Active Movement Studio Rescheduling Policy* Your reserved class time has been specifically allocated to you. To achieve maximum improvement in the shortest possible timeframe, it is vital that you maintain attendance. If you are unable to make your scheduled class time, a minimum of 24 hours notice is expected. A courtesy phone call or email to reschedule your appointment is appreciated. We thank you for corporation and understanding. Let's Stay Connected I give AMS permission to register me to receive exclusive promotions, free health advice, hear the latest fitness trends, access our workout of the month and gain exclusive invitations to our workshops and more. Client Consent* I have read and understand the above information and give my consent to participate in the Group Training Classes hosted by AMS. Sign - Type Full Name*
