Registration Form

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Pre-Exercise Screening Form & Waiver

This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by K2Fitness for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool.

AIM: To identify those individuals with a known disease, or signs or symptoms of disease, that may be at a higher risk of an adverse event during physical activity or exercise. This form is self administered and self-evaluated.

Name

First Name

Last Name

1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?

2. Do you ever experience unexplained pains in your chest at rest or during physical activity?

3. Do you ever feel faint or have spells of dizziness during physical activity that causes you to lose balance?

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?

6. Do you have any diagnosed muscle; bone or joint problems that you have been told could be made worse by participating in physical activity?

7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity?

WAIVER In choosing to take the opportunity to participate in personal/ triathlon training, I, for myself: 1. Acknowledge, agree and represent that I understand the nature of personal training, and that I am in good health, and in proper physical condition to participate in such activity. 2. Fully understand that: (a.); personal training and triathlon activities involve risks and dangers of serious bodily injury, including permanent disability, paralysis and death ("risks"); (b.) These risks and dangers may be caused by my own actions, or inactions, the actions or inactions of others participating in the activity, or the condition in which the activity takes place; (c.); there may be other risks either not known to me or not readily foreseeable at this time; and I fully accept and assume all such risks I incur as a result of my participation in the activity. 3. Agree and warrant that I will examine and inspect each activity/exercise in which I take part as a client and that, if I observe any condition which I consider to be unacceptably hazardous or dangerous, I will notify the proper authority in charge of the activity/exercise and will refuse to take part in the activity/exercise until the condition has been corrected to my satisfaction.

Signature

I believe that to the best of my knowledge, all of the information I have supplied within this tool is correct.

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Date

YYYY

IF YOU ANSWERED ‘YES’ to any of the 7 questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity.

IF YOU ANSWERED ‘NO’ to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity.