Pre-Exercise Questionnaire Personal DetailsPlease read the following questionnaire carefully. Elixr recommends that anyone engaging in a new fitness program consult their doctor before doing so. Persons under 16 years of age must be supervised by an adult when using club facilities.Full Name(Required) First Name Last Name Email Address(Required) Phone Number(Required)Date of Birth(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderPlease select from listFemaleMaleOtherAddress Street Address Suburb State Post Code Emergency Contact InformationAustralian emergency contact information only. No international phone numbers.Emergency Contact Name(Required) First Name Last Name Emergency Contact Phone Number(Required)Pre-Exercise QuestionnaireIf you have any questions or do not understand something on this form, please ask a member of Elixr staff before you sign and complete.1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?(Required) Yes No 2. Have you recently developed or do you have any chest pain brought on by physical activity / exercise?(Required) Yes No 3. Has physical activity caused you to lose consciousness or to fall over as a result of dizziness / feeling faint?(Required) Yes No 4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?(Required) Yes No 5. If you have diabetes (type 1 or type 2) have you had trouble controlling your blood glucose in the last 3 months?(Required) Yes No 6. Do you have any other conditions that may require special consideration for you to exercise?(Required) Yes No 7. Are you currently pregnant or have given birth in the last 8 weeks?(Required) Yes No This field is hidden when viewing the form8. Are there any other permanent medical conditions you may have that may affect your ability to exercise safely. Yes No If I have answered “yes” to any of the questions, I will seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise. I hereby state that I have read, understood and answered honestly the questions and that any statements made by me in answering the Pre-Exercise Questionnaire are true and accurate. I also state that I wish to participate in activities which may include exercise (aerobic and resistance) and swimming. I realise that my participation in these activities involves the risk of injury and the possibility of death. I hereby confirm that I am voluntarily engaging in an acceptable level of exercise given my knowledge of my health and considering any medical advice I have received. I acknowledge that if I am under 16 years of age I must be supervised by an adult when using club facilities. I understand and agree that Elixr Health Clubs may reject my application to use the club as a result of information provided in this questionnaire, any medical certificate I provide or if Elixr Health Clubs has reasonable grounds for believing that engaging in physical activity may be harmful to my health or safety. We may retain this Pre-Exercise Questionnaire, and the information contained in it for a reasonable length of time for the sole purposes of maintaining complete records of pre-activity applications, verifying previous health / medical history and for assessing any future application for membership by you. You have the right to access the personal information we have collected about you and it is your responsibility to update this information if it is no longer accurate. Please visit or call Elixr on (02) 8113 8800 for more information.Signature(Required)