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Online Screening Form

Conquer Coaching Online Screening Form

In order for us to best help you, there are some facts we need to know about you. Please complete the form below and send it to us and we will be in touch with you soon. If you have any questions, please feel free to contact us.

First Name *
Last Name *
Gender *
MaleFemale
Date of Birth *
Phone *
Email *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Weight (kg) *
Height (cm) *
How did you hear about us? *

Health Background Screening

Do you suffer from a heart condition or have ever had any form of heart disease, previously suffered a heart attack, or have a family history of heart disease? *
YesNo
Do you experience any pain while undertaking physical activity or exercising? *
YesNo
Have you ever experienced faintness, dizziness, shortness of breath, or experienced a loss of balance while undertaking physical activity or exercise? *
YesNo
Do you have diabetes or suffer from high blood pressure? *
YesNo
Do you suffer from asthma? *
YesNo
Do you have a bone or joint problem that could be aggravated by a change in your level of physical activity? *
YesNo
Do you smoke?
YesNo
If ‘Yes’ to smoking, how long for?
Are you pregnant or have you given birth in the last 12 months? *
YesNo
Have you been hospitalised in the last 12 months? *
YesNo
Do you have any other medical condition or injury, currently taking medication, or know of any other reason that would prevent you from exercising? *
YesNo
Comments

Current Activity Level

Describe your current weekly physical activity level *
LowLow - MediumMediumMedium - HighHigh
Describe your weekly activity / exercise routine *
Have you had any significant injuries / operations / hospitalisations in the past that could prevent you from exercising? *

Fitness Goals

What would you like to achieve from your Personal Training Sessions? *
Weight LossDecrease Body FatIncrease Lean MuscleWeight Gain
Your Goals: (Think SMART goals: Specific, Measurable, Attainable, Realistic & Timely) *

Food Allergies / Dislikes

Please specify any dietary requirements

Measurements

Body Girths (cm)
Biceps *
Chest *
Waist *
Buttocks *
Thigh *
Calf *
Skin Folds (mm)
Triceps
Biceps
Subscapular
Umbilical
Iliac Crest
Supra
Thigh
Calf
Terms & Conditions The undersigned, understands, acknowledges and agrees that: (i) I am aware that the facilities and services offered by Conquer Fitness involve risks, included but not limited to, risk of bodily injury: (ii) I have provided above all the relevant information regarding medical history and current health status: (iii) I am making use of the fitness facilities of Conquer Fitness at my own free will; and (iv) I assume all risks associated therewith. On behalf of myself and my heirs I hereby release and discharge the entity that operates Conquer Fitness (the ‘owner’) and all the affiliates, subsidiaries, employees, directors, officers, agents, landlords, representatives, successors and assigns of the Owner from any and all claims or causes of action arising out of or relating to my use of the facilities and services of that entity, including but not limited to, those resulting from bodily injury or theft, or loss of, or damage to, property of mine unless due to gross negligence or wilful misconduct of the Owner or it’s employees.
I agree to the above terms & condtions *
I agree
Name *
Date *

Verification

Please enter any two digits *Example: 12
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