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Pre-Exercise Form
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Pre-exercise Form (Adult)
First name
(Required)
Last name
(Required)
Phone
(Required)
Email
(Required)
Emergency Contact NAME and NUMBER
(Required)
1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
(Required)
Yes - Medical clearance required
No
2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
(Required)
Yes - Medical clearance required
No
3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?
(Required)
Yes - Medical clearance required
No
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
(Required)
Yes - Medical clearance required
No
5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
(Required)
Yes - Medical clearance required
No
6. Do you have any other conditions that may require special consideration for you to exercise?
(Required)
Yes - Medical clearance required
No
Is there anything else you would like to add?
PLEASE SELECT ALL THAT APPLY
(Required)
I confirm that the information I have provided is true and accurate to the best of my knowledge.
I understand that Villagefit classes are general group fitness sessions and are not a substitute for medical advice, diagnosis, or treatment.
I acknowledge that participation in physical activity involves inherent risks, and I agree that I am voluntarily taking part in these activities.
I agree to inform VillageFit of any changes to my health, medical conditions, pregnancy status, or injuries that may affect my ability to participate safely.
I understand that Villagefit may require medical clearance prior to participation where appropriate.
Signature
(Required)
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