TRIAL SESSION FORM

/ office use only

Name of Trainer:
Location:
Suit Size:

/ GENERAL INFORMATION

First:
Surname:
Date of Birth:
Sex:
Full Address:
Email:
Phone: (Work)
(Home)
Mobile:
Occupation:
Family Doctor Name:
Practice Address:
Phone:
What is (are) your purpose(s) for participating in the 20PerFit program?
How did you find out about 20PerFit?

/ EMERGENCY CONTACT

In the event of an emergency who would you like us to contact

Emergency Contact Person:
Contact numbers:
Name:
Phone:
Relationship:
Mobile:
Work:

/ MEDICAL HISTORY

This is your medical history form, to be completed prior to your first training session. All information will be kept confidential. This information will be used for the evaluation of your health and readiness to begin our exercise program. The form is extensive, but please try to make it as accurate and complete as possible. Please take your time and complete it carefully and thoroughly, and then review it to be certain you have not left anything out. Your answers will help us design a comprehensive program that meets your individual needs.

If you have questions or concerns, we will help you with those after this form is completed. We realize that some parts of the form will be unclear to you, however we require you to answer each question honestly and to the best of your knowledge. If you have any questions ask our trainer and your questions will be thoroughly addressed afterwards. It might be helpful for you to keep a written list of questions or concerns as you complete the medical history form.

/ PLEASE CHECK THE BELOW QUESTIONS

Yes
No
Do you have a pacemaker?
Yes
No
Do you have a heart condition or have you ever suffered a stroke?
Yes
No
Do you suffer from high blood pressure?
Yes
No
Are you pregnant?
Yes
No
Do you have a severe neurological disease/ disorder (i.e. Epilepsy)?
Yes
No
Do you currently suffer from a severe vascular disorder?
Yes
No
Did you have any surgery within the last month?
Yes
No
Do you suffer from any kind of hernia?
Yes
No
Do you currently suffer from tuberculosis?
Yes
No
Have you had an asthma attack in the last 12 months?
Yes
No
Do you know of any tumours you had and/or might have?
Yes
No
Do you have arterial atherosclerosis in the advanced stage?
Yes
No
Do you have stents?
Yes
No
Do you have severe diabetes?
Yes
No
Do you have any fever and/ or acute bacterial or viral processes?
Yes
No
Do you suffer from bleeding, severe bleeding problems (haemophilia)?
Yes
No
Are you a smoker?
Yes
No
Do you have any diagnosed muscle, bone or joint problems (like lower back pain, knee injury, shoulder pain…)?
Yes
No
Do you have any metal implants?
Yes
No
Further or other permanent or acute diseases?
Yes
No
If yes, please specify?
Please list any prescription medications which you take:
Please list any self-prescribed medications, dietary supplements, or vitamins you are now taking:
Please list any allergies (include drug allergies)
If you answered “yes” to any of the above questions, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise

/ Information about EMS

EMS = Electro-Muscular-Stimulation
EMS imitates the natural action of the central nervous system, sending electrical impulses to contract deep muscles fibres in just 20 minutes.
/ IMPORTANT NOTE:
This document affects your legal rights and obligations. Please read it carefully and do not sign it unless you understand lt. If you have any questions please ask.
(If you under 18 this form must be read, understood and signed by a parent or legal guardian)
/ Disclaimer
  • You should consult your doctor or other health care professional before starting this or any other fitness program to determine if it is right for your needs. This is particularly true if you (or your family) have a history of high blood pressure or heart disease, or if you have ever experienced chest pain when exercising or have experienced chest pain in the past month when not engaged in physical activity, smoke, have high cholesterol, are obese, or have a bone or joint problem that could be made worse by a change in physical activity. Do not start this program if your doctor or health care provider advises against it. If you experience faintness, dizziness, pain or shortness of breath at any time while exercising you should stop immediately.
  • You should not rely on any information given to you as a substitute for, nor does it replace, professional medical advice, diagnosis, or treatment. If you have any concerns or questions about your health, you should always consult with a doctor or other health-care professional. Do not disregard, avoid or delay obtaining medical or health related advice from your health-care professional because of something you have been told or may have read. The use of any information provided to you is solely at your own risk.
/ Release, Acknowledgment of Risk, and Waiver of Liability
  • 1.1I understand, recognise and acknowledge that EMS ad the training program that I am about to undertake and be involved in has been explained to me.
  • 1.2I understand, recognise, and acknowledge that certain activities conducted or taking place by us or our trainers (in whatever location) are potentially hazardous and may involve the risk of accident, death, illness, physical or mental injuries, and property damage. It is my responsibility to ask questions about any aspect of the program activities that have not been explained to my satisfaction. I hereby voluntarily assume any and all risks, including injury to person and property, related to my participation and/or my child›s participation in the program.
  • 1.3I further understand that, notwithstanding precautions taken by 20Perfit or its trainers, sports and fitness activities/programs involve a risk of injury and/or death. I/we are voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. In signing this Contract, I hereby acknowledge that I have read this entire document, that I understand its terms, that I have signed it knowingly and voluntarily, and that I intend it to bind me and, as applicable, my child/children and anyone claiming on behalf or me or my child/children.
  • 1.4We will, unless excused from liability by operation of statute, compensate you for death, personal injury, illness or property damage caused by gross negligence on our part and for loss and damage to your personal property arising from our failure to supply services to you with due care and skill and in a manner fit for the purpose which is reasonable to expect in all the circumstances.
/ Indemnity
  • 1.5In consideration of the grant of membership to you, entitling you to engage in fitness activities,
    you hereby otherwise:
    • (a)agree, to the extent permitted by law, to not hold us liable for any actions, suits, proceedings, claims, demands, losses, damages, penalties, fines, costs and expenses however arising that you may have had but for this clause arising from or in connection with your involvement in fitness activities at 20Perfit by usor our trainers or using our facilities (irrespective of the location), services or products;
    • (b)agree that you will indemnify us to the extent permitted by law in respect of all actions, suits, proceedings, claims, demands, losses, damages, penalties, fines, costs or expenses however arising as a result of or in connection with your involvement in fitness activities at by us or our trainers or using our facilities (irrespective of the location), services or products.
/ Please note the following safety instructions:
  • In the event that you suffer or may suffer from any of the following, you are not permitted to undertake or participate in any of the 20Perfit training program. These Contraindications may include Epilepsy, heart pacemaker, pregnancy and or heavy blood circulation disorders. Please note this is not an exhaustive list and 20Perfit reserves the right to refuse participation in the training program, such refusal to be at 20Perfit sole discretion.
  • In general, if you suffer or may suffer from any of the following, training may not be commenced except with the prior medical approval of your doctor: abdominal wall or inguinal hernia, tuberculosis, tumour diseases, Arteriosclerosis in advanced stadium, arterial blood circulation disorders, heavy neurological diseases, diabetes mellitus, aguish diseases, acute bacterial or viral processes, bleedings, heavy bleeding tendency (haemophilia).
/ IMPORTANT NOTE:
This document affects your legal rights and obligations. Please read it carefully and do not sign it unless you understand lt. If you have any questions please ask.
(If you under 18 this form must be read, understood and signed by a parent or legal guardian)
/ Disclaimer
  • You should consult your doctor or other health care professional before starting this or any other fitness program to determine if it is right for your needs. This is particularly true if you (or your family) have a history of high blood pressure or heart disease, or if you have ever experienced chest pain when exercising or have experienced chest pain in the past month when not engaged in physical activity, smoke, have high cholesterol, are obese, or have a bone or joint problem that could be made worse by a change in physical activity. Do not start this program if your doctor or health care provider advises against it. If you experience faintness, dizziness, pain or shortness of breath at any time while exercising you should stop immediately.
  • You should not rely on any information given to you as a substitute for, nor does it replace, professional medical advice, diagnosis, or treatment. If you have any concerns or questions about your health, you should always consult with a doctor or other health-care professional. Do not disregard, avoid or delay obtaining medical or health related advice from your health-care professional because of something you have been told or may have read. The use of any information provided to you is solely at your own risk.
/ Release, Acknowledgment of Risk, and Waiver of Liability
  • 1.1I understand, recognise and acknowledge that EMS ad the training program that I am about to undertake and be involved in has been explained to me.
  • 1.2I understand, recognise, and acknowledge that certain activities conducted or taking place by us or our trainers (in whatever location) are potentially hazardous and may involve the risk of accident, death, illness, physical or mental injuries, and property damage. It is my responsibility to ask questions about any aspect of the program activities that have not been explained to my satisfaction. I hereby voluntarily assume any and all risks, including injury to person and property, related to my participation and/or my child›s participation in the program.
  • 1.3I further understand that, notwithstanding precautions taken by 20Perfit or its trainers, sports and fitness activities/programs involve a risk of injury and/or death. I/we are voluntarily participating in these activities and using equipment and machinery with knowledge of the dangers involved. In signing this Contract, I hereby acknowledge that I have read this entire document, that I understand its terms, that I have signed it knowingly and voluntarily, and that I intend it to bind me and, as applicable, my child/children and anyone claiming on behalf or me or my child/children.
  • 1.4We will, unless excused from liability by operation of statute, compensate you for death, personal injury, illness or property damage caused by gross negligence on our part and for loss and damage to your personal property arising from our failure to supply services to you with due care and skill and in a manner fit for the purpose which is reasonable to expect in all the circumstances.
/ Indemnity
  • 1.5In consideration of the grant of membership to you, entitling you to engage in fitness activities,
    you hereby otherwise:
    • (a)agree, to the extent permitted by law, to not hold us liable for any actions, suits, proceedings, claims, demands, losses, damages, penalties, fines, costs and expenses however arising that you may have had but for this clause arising from or in connection with your involvement in fitness activities at 20Perfit by usor our trainers or using our facilities (irrespective of the location), services or products;
    • (b)agree that you will indemnify us to the extent permitted by law in respect of all actions, suits, proceedings, claims, demands, losses, damages, penalties, fines, costs or expenses however arising as a result of or in connection with your involvement in fitness activities at by us or our trainers or using our facilities (irrespective of the location), services or products.
/ Please note the following safety instructions:
  • In the event that you suffer or may suffer from any of the following, you are not permitted to undertake or participate in any of the 20Perfit training program. These Contraindications may include Epilepsy, heart pacemaker, pregnancy and or heavy blood circulation disorders. Please note this is not an exhaustive list and 20Perfit reserves the right to refuse participation in the training program, such refusal to be at 20Perfit sole discretion.
  • In general, if you suffer or may suffer from any of the following, training may not be commenced except with the prior medical approval of your doctor: abdominal wall or inguinal hernia, tuberculosis, tumour diseases, Arteriosclerosis in advanced stadium, arterial blood circulation disorders, heavy neurological diseases, diabetes mellitus, aguish diseases, acute bacterial or viral processes, bleedings, heavy bleeding tendency (haemophilia).
Signature of Member:
Witness:
Date:

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