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PRE-EXERCISE/LIFESTYLE SCREENING QUESTIONNAIRE

Please take a few minutes to answer the following questions.

Name: _____________________ DOB: ___/___/___ Age: _____ Sex: M / F Emergency Contact Name:_______________________ Ph:_____________ Occupation: ______________________ Have you used a gym before? Y / N Part A: Medical Considerations It is our professional duty of care to ask all participants, no matter what age, to complete the following questions. Please check box when applicable to indicate Yes. Has a family member, under 60, suffered from heart disease, stroke, raised cholesterol or sudden death?............................................................................................................................☐ Are you a male over 35 or female over 45 and NOT used to regular vigorous exercise?..............☐ Are you on any prescribed medication?................................................................................☐ Have you been hospitalized recently?..................................................................................☐ Are you pregnant?....................................................................................................................................................................☐ Have you given birth in the last 6 weeks?....................................................................................................................☐ Do you have any infections or infectious diseases?................................................................☐ Do you have or have you had: ☐ Heart condition/stroke/Heart Murmur ☐ Hernia ☐ A family history of heart disease ☐ Stomach Ulcer ☐ Palpitations or Pain in Chest ☐ Arthritis ☐ High or Low Blood Pressure ☐ Asthma/breathing difficulties ☐ Epilepsy ☐ Dizziness, Fainting or Headaches ☐ Diabetes ☐ Circulation Problems ☐ Hypoglycemia ☐ Infectious Diseases ☐ Liver/Kidney Condition Any major injuries/surgery or other medical conditions not listed above. If so, please provide details below: _____________________________________________________________________________ _____________________________________________________________________________

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Do you have any Pain or Major Injuries in the following areas: Neck………..☐ Knees………☐ Back………..☐ Ankles……..☐ Please give details of any conditions: _____________________________________________________________________________ _____________________________________________________________________________

If you have ticked any of the above, you need a signed medical clearance from your doctor before starting exercise. Doctors clearance: _____________________________ Date: ___/___/___ Or I warrant that I am physically and mentally well enough to proceed with usage of the facility. Clients self clearance of the above conditions: _____________________ Date: ___/___/___

Part B: Lifestyle and current exercise habits Are you currently exercising regularly? Yes ☐ No ☐ • If yes, please give details below: • Type of exercise: • Frequency of exercise (times per week): 1 ☐ 2 – 3 ☐ 3 – 4 ☐ 5+ ☐ • Perceived intensity when exercising: Hard ☐ Medium ☐ Light ☐ V Light ☐ Do you smoke? Yes ☐ No ☐ • If yes, how many per day? 1 – 5 ☐ 6 – 10 ☐ 11 – 15 ☐ 16 – 20 ☐ 21 - 25 ☐ 25+ ☐ Are you allergic to anything? _______________ Part C. Please ✔ what you hope to achieve • To reduce body fat ☐ • To improve aerobic capacity (heart/lung fitness) ☐ • To gain some muscle definition ☐ • To gain overall fitness ☐ • To generally tone up ☐ • To gain strength ☐ • Other __________________________________ ☐ Additional information: _____________________________________________________________________________ _____________________________________________________________________________

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Please read the following exercise advice carefully. Ask any staff member to guide you into the most suitable class or program. Work at a low level on your first visit and concentrate on learning to do the exercises properly. On each visit you will be able to work a little harder. Be sure to limit yourself to a pace where you can still talk comfortably. Should you suffer an injury, illness or conditions in the future please tell us by completing this form again. It is recommended that all males over 35 and females over 45 should have a medical assessment including an exercise ECG and cholesterol/lipid count. Statement I recognise that the instructor is not able to provide me with medical advice with regard to my fitness, and that this information is used as a guideline to the limitations of my ability to exercise. I have answered questions to the best of my ability and understand the advice above. Signed: ___________________________________________ Date: ___/___/_____________

IMPORTANT:

This Pre-Exercise Screening form is to be completed by any person who wishes to participate in any activity run by, or in connection with, Miguel Vogeler and Maria Ginestra t/a Zumba MC Fitness [ABN 77 126 805 994] ("the Participant"). This Pre-Exercise Screening form contains a limitation of liability and should be read carefully. Please contact Miguel Vogeler if you require clarification of the terms and conditions set out below.

TERMS AND CONDITIONS I, ________________________________, ("the Participant") in consideration of Miguel Vogeler and Maria Ginestra t/a Zumba MC Fitness [ABN 77 126 805 994] (“Zumba MC Fitness”) agreeing to accept me as a Participant, hereby acknowledge and agree that, to the extent permitted by law:

I acknowledge that the activity I am to undertake is potentially a dangerous activity and that I accept the risks, which participating in such activity exposes me to. I declare that am physically and mentally fit to proceed with the normal routine of exercise.

I acknowledge and understand that whilst participating in the activity I may be injured, physically and mentally, and potentially fatal accidents can occur. I acknowledge and understand that any minor/child who is under my care and/or supervision that attends at an activity with me may be injured, physically and mentally, which may result in fatal cause. I acknowledge and understand that there may be theft, loss, damage or injury to my personal property. If I am injured there may be no or inadequate facilities for treatment or transport. I assume the sole risk and responsibility for any injury, death, or property damage resulting from my participation in the activity.

Zumba MC Fitness accepts no responsibility for any loss, damage, injury or death caused to me or my personal property due to conditions beyond their control. Including, but not limited to, weather, grounds, and exercise equipment.

I hereby waive all claims (whether legal or otherwise), release, indemnify and shall keep indemnified Zumba MC Fitness (including, but not limited to, its owners, instructors, employees, officers, servants or agents) with respect to any Liability, theft, damage, loss, or injury, to myself or my personal property, arising out of or in connection with my participation in any activity or exercise program, or use of facilities associated with any activity or exercise program.

In the case of a Participant being under the age of 18 years old ("Minor"), I ______________________ [Parent or Guardian] hereby waive all claims (whether legal or otherwise), release, indemnify and shall keep indemnified Zumba MC Fitness (including, but not

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limited to, its instructors, employees, officers, servants or agents) with respect to any Liability, theft, damage, loss, or injury, to the above named Minor, or the above named Minor's personal property, arising out of or in connection with the above named Minor's participation in any activity or exercise program, or use of facilities associated with any activity or exercise program.

"Liability" means liability for death, personal injury (physical and mental), personal property, and otherwise (whether actual, contingent or prospective), losses, damages, costs, expenses and fees of any description (including liability arising as a result of Zumba MC Fitness negligence, omission, breach of contract or otherwise).

I accept the terms and conditions set out above following careful consideration of their scope and intent. I acknowledge that I have had a reasonable opportunity to read and understand this Pre-Exercise Questionnaire. I accept the exclusions of liability contained herein and have sought direction and clarification from Miguel Vogeler (where necessary). I have taken independent legal advice or have been given the opportunity to take legal advice as to the nature, effect and extent of this document in order to exercise a considered choice in accepting these terms and conditions. The information contained in this form is true and accurate to the best of my knowledge.

Signed (Participant):____________________ Date:____/_____/_____

Signed (Miguel Vogeler):__________________ Date:____/_____/_____

Miguel Vogeler - TRX Group Training - m. +61 402 692 802 - e. trxgrouptraining@gmail.com

w. www.trxgrouptraining.com.au