Health & Lifestyle Questionnaire

Health & Lifestyle Questionnaire

Please read through the following information and fill out the fields as necessary. Fields marked with an * are mandatory, and you will need to agree to the terms and conditions listed below before submission.


Full Name: *
Date of Birth: *
 /  / 
Address: *
Postcode: *
Phone: *
-
E-mail: *

We do not want to unnecessarily worry you or your doctor, but it is very important to check out any possible risks to your health and safety before you have a fitness appraisal or start on your exercise programme.

Medical History

Please indicate below if any of the conditions listed below have applied to you:
Please gives details of the condition (if applicable):
Please indicate any other conditions, which might affect your exercise programme:
Have you ever had any major surgery? If so, please give details:
Do you take any medication?
Do you have any family history of heart disease? *

Lifestyle Questionnaire

What are your fitness goals? *
Have you currently been involved in any regular exercise? *
What is your occupation? *
How would you rate your daily physical activity levels? *
Do you smoke? *
How many standard alchoholic drinks per week do you consume? *
Do you know of any reasons why you should not do physical exercise? *

Terms and Conditions

Please read these terms and conditions carefully before agreeing to participate in a Fitness Session.


1. DEFINITIONS FOR THE PURPOSE OF THIS AGREEMENT:-

“PLT” means Positive Lifestyle Training. ABN 2509963618

“You” means the individual who is undertaking a Fitness Session with PLT and that has agreed to accept these terms and conditions.

“Fitness Sessions” shall mean any period during which You shall be instructed by PLT in physical exercise.

“Session Fee” shall mean the fee payable by You for each Fitness Session or a series of Fitness Sessions payable by You.


2. YOUR OBLIGATIONS

a. Should PLT consider it necessary, You agree that a representative from PLT may contact your doctor in relation to You undertaking one or more Fitness Sessions and You agree that you will comply with any doctor’s instructions regarding your participation in such Fitness Sessions and any subsequent exercise that PLT suggest You undertake.
b. You agree to complete the Fitness Questionnaire attached to this document to the best of your knowledge and ability.
c. You agree to wear suitable footwear and clothing during all Fitness Sessions and any subsequent exercise that PLT suggest You undertake.

3. ACCEPTANCE

a. PLT shall have absolute discretion whether or not to accept an application for a Fitness Session or series of Fitness Sessions by You.
b. An application for the Fitness Session will be accepted by PLT upon the date and time of the Fitness Session being confirmed by PLT.
c. You acknowledge that participation in any exercise program may increase the risk of injury to You.
d. You acknowledge that the level of my participation in the exercise program and which exercises to perform must be determined by You, in consultation with Your doctor, and that PLT and its instructors are not responsible for the intensity of Your participation.
e. You acknowledge that PLT’s instructors are not doctors, nurses, or emergency medical technicians, and that the instructor and PLT, by making the exercise program available, are not undertaking any responsibility regarding Your medical condition(s). If my medical condition should change, You agree and understand that it is Your responsibility to discontinue the exercise program and to immediately consult with Your doctor about continuing or resuming participation in this or any exercise program.
f. You agree to personally assume any and all risks associated with participating in a Fitness Session with PLT.


4. INDEMNITY AND LIMITATION OF LIABILITY

a. You agree to hereby release, indemnify and hold harmless PLT, and the instructors of the exercise program You have chosen to attend, its respective employees, contractors, directors, and agents, from any and all claims, demands, personal injuries, costs, or expense, arising from or relating in any way to my participation in a Fitness Session.
b. In consideration of PLT accepting the application for a Fitness Session You agree that; -
i. PLT will not be liable for any loss, damage or theft of Your personal property; and
ii. the use of the equipment provided by PLT and/or the exercises undertaken by You whether during the Fitness Session or otherwise is entirely at Your own risk and PLT will not be liable for any injury that results from your participation in a Fitness Session.


5. YOUR PHYSICAL CONDITION

a. You warrant and represent that you are in good physical condition and that You are capable of engaging in active or passive exercise and that such exercise would not be detrimental to Your health, safety, and comfort of physical condition.
b. By agreeing to accept these terms and conditions, You warrant that to the best of Your knowledge and belief You are not suffering from any physical disability or illness whether or not such disability or illness is or may be affected by exercise of whatever degree, and further warrant to advise PKT and its Instructors if, You begin to suffer from a new disability or illness and You agree to indemnify PLT and its instructors in respect of any disability or illness whether suffered in the class or otherwise.

6. PAYMENTS

Subject to any special terms in the Fitness Session application, the Session Fee shall be paid one week in advance of the date of the Fitness Session.


7. CANCELLATION

a. PLT may cancel any Fitness Session by providing 24 hour notice to You. Any advance payments made for the Fitness Session shall be returned to You.
b. You may cancel the Fitness Session by giving 24 hours’ notice to PLT. Notice of the cancellation should be given to PLT by telephoning 0421 572 914. Should You fail to give 24 hours’ notice PLT shall not be obliged to return the any Session Fee.


8. TERMINATION

PLT reserve the right to terminate all Fitness Sessions immediately and retain any pre-paid Session Fees should: -
a. You fail to comply with, or breach any of the conditions of these terms and conditions; or
b. supply any fraudulent or wrongful information relating to Your health or personal details.


9. GOVERNING LAW AND JURISDICTION

These Terms and Conditions and any agreement between You and PLT will be governed by and shall be construed in accordance with the laws of Western Australia. The parties must submit to the exclusive jurisdiction of the court of Western Australia.


By clicking “I Agree” below and completing the Health and Lifestyle Questionnaire You:

a. agree to accept the PLT Terms and Conditions as set out herein;
b. acknowledge that You have read and understand these Terms and Conditions; and
c. acknowledge that You have been given the opportunity to ask any questions and have received and understood all of the information provided to You.
d. agree that the information I have supplied is correct to the best of my knowledge and that I have not omitted and information that I believe may be relevant.

AGREEMENT *


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