Croí Exercise Form Home / Croí Exercise Form Name(Required) First Last Gender(Required)FemaleMaleAge(Required)Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency Contact/Next of Kin Name(Required) Emergency Contact/Next of Kin Phone Number(Required) GP Name(Required) Has your Doctor ever said to you that you should only do physical activity or exercise as recommended by a Doctor?(Required)YesNoDo you ever feel pain in your chest, jaw or left arm when doing physical activity or exercise?(Required)YesNoDo you ever feel pain in your chest, jaw or left arm at rest?(Required)YesNoDo you ever lose your balance due to dizziness or do you ever lose consciousness?(Required)YesNoDo you have a bone or joint problem that could be made worse by a change in your physical activity?(Required)YesNoHave you ever experienced any pain whilst exercising which caused you to stop?(Required)YesNoHave you ever suffered any musculoskeletal injury, e.g. ligament strain, tendon or muscle injury or fractures (broken bones)?(Required)YesNoAny other relevant information that the instructor should be made aware of, e.g pregnancy or any recent diagnosis that may impact on your exercise participation?(Required)YesNoPlease provide details if releventOther Medical Conditions(Required)StrokeEpilepsyClaudicationCOPD/AsthmaNeuro ProblemsRecent Cardiac EventOtherNoneIf other, please specifyConsent(Required) I confirm that I have read and understood the terms stated below.Disclaimer: If you answered yes to any of the above questions, talk with your doctor BEFORE you become physically active. Tell your doctor of your intention to exercise and which questions you answered ‘yes’ to. If at any stage your health changes, resulting in a ‘yes’ answer to any of the above questions, please seek guidance from a GP and inform your Croí exercise instructor.Consent(Required) I confirm that I have read and understood the terms stated below. If there are any future changes to your medical health or prescribed medications, please notify the class instructor.Disclaimer: Participating in this activity is done at your own risk. Croí cannot be held responsible or liable for any injury or harm incurred while participating in this activity. Please keep properly hydrated throughout the session. If you feel unwell at the beginning of the session or at any stage during the session, please inform the instructor/leader/teacher.