ADULT PRE EXERCISE SCREENING

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 Konti, it’s partners or Steven Kontowicz, for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool.

TO ASSIST ME IN PREPARING A CUSTOMISED PROGRAM, PLEASE COMPLETED AND SUBMIT THE FORM BELOW

Name *

First

Last

Email *

Date of Birth

Gender

Female
Male

GIft Voucher Code

If you have a gift voucher code please add it here

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/exercise?

3. Do you ever feel faint or have spells of dizziness during physical activity/exercise 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/exercise?

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

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/exercise.

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/exercise

Goal Setting

Weight Loss
Build Muscle
Increase Strength
Endurance
Toning
Preseason Training
Other (Please Specify Below)

Please specify your goals

Measurements

Weight (KG)

Height (CM)

Chest (CM)

Waist (CM)

Hips (CM)

Legs (CM) Right Leg

Legs (CM) Left Leg

Arm (CM) Left Arm

Arm (CM) Right Arm

Diet & Allergies

Please specify any specific dietary requirements and/or allergies you may have

Describe your current physical activity/exercise level:

Sedentary
Light
Moderate
Vigorous

Frequency (sessions per week)

Duration (minutes per session)

What type of physical activity/exercise do you currently undertake?

Are you pregnant, recently had surgery or have any injuries that will limit your ability to exercise?

Do you have access to commercial gym facilities?

How many days per week can you train?

Any other information you would like to provide and has not been covered?

OPTIONAL: Progress photo upload

Click or drag files to this area to upload. You can upload up to 3 files.

While not compulsory, to further assist in designing your customised training program, you have the option of sending through full length photo’s showing your front, side and back. It is preferable that the photos be taken in your undergarments against a plain background. The photos will be used specifically for assessment purposes and will not be published on any platform without your prior consent.

By submitting this form you agree that to the best of your knowledge, all of the information you have supplied within this form is correct.

Confirmation of conditions *

I confirm the information submitted in this form is accurate to the best of my knowledge

Confirmation of conditions (copy) *

I have read and agree to the personal training cancellation policy

At Konti Fitness we understand emergency's happen and we will try to be as accommodating as possible to reschedule your appointment before cancelling it. If a rescheduled appointment can be made for that day - we will endeavour to change the time for you. In the circumstance, that the appointment needs to be cancelled we will abide by following policy:
* All appointments for personal training will be scheduled directly between the personal trainer (Konti Fitness PT) and the client.
* Subsequently, if a client has to cancel or reschedule any previously scheduled appointments, the client must contact the personal trainer directly at least 8 hours in advance of the scheduled appointment.
* If a client does not cancel or reschedule an appointment at least 8 hours in advance, Konti Fitness reserves the right to charge a cancellation fee equivalent to a full personal training fee that would normally be charged for that training session. If a client is on a pt package - one pt session will be taken due to cancellation.
* If a client fails to appear for a scheduled appointment, Konti Fitness will charge the full fee equivalent to the personal training fee that would have been charged for the training session. If a client is on a pt package - one pt session will be taken.
* All cancellations must be made 8 hours in advance by phone or text.

Personal Training Package Refunds Policy.
* When Personal Training Sessions are purchased in a "pack" - no refund will be offered for unused sessions. The discounted price per session is based on the whole package price.

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ADULT PRE EXERCISE SCREENING

Measurements

By submitting this form you agree that to the best of your knowledge, all of the information you have supplied within this form is correct.

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