Client Screening & Agreement Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone Number Have you ever been told that you have a heart condition? * Yes No Have you ever had a stroke? * Yes No Do you ever have unexplained pains in your chest at rest or during physical exercise? * Yes No Do you consistently feel faint or suffer from spells of dizziness? * Yes No Do you suffer from asthma and require medication? * Yes No Do you suffer from type I or II diabetes? * Yes No Do you suffer from any major muscle or joint conditions that may limit you or be aggravated by physical activity? * Yes No Do you suffer from any medical conditions that may be made worse by participating in physical activity? * Yes No Do you suffer from high blood pressure over 140/90 or low blood pressure below 100/80? * Yes No I agree to Efficient Effort Terms and Conditions * Disclaimer: If you have answered no to all of the above questions and you are confident that you have no other concerns with your health then you may proceed to participate in physical activity. If you have answered yes to any of the questions above or are unsure, please seek a referral from your GP or allied health professional before commencing physical activity. I believe to the best of my knowledge that all of the information I have provided on this tool is accurate. In the case that my medical condition changes over the course of my training I will inform my trainer and fill out a new exercise pre-screening questionnaire. By ticking yes below, this confirms that you have read, and agree to our Terms and Conditions. Yes Thank you!
