Croí Exercise Form

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Name(Required)

First Last

Gender(Required)

Age(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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)

Please provide details if relevent

Do you ever feel pain in your chest, jaw or left arm when doing physical activity or exercise?(Required)

Please provide details if relevent

Do you ever feel pain in your chest, jaw or left arm at rest?(Required)

Please provide details if relevent

Do you ever lose your balance due to dizziness or do you ever lose consciousness?(Required)

Please provide details if relevent

Do you have a bone or joint problem that could be made worse by a change in your physical activity?(Required)

Please provide details if relevent

Have you ever experienced any pain whilst exercising which caused you to stop?(Required)

Please provide details if relevent

Have you ever suffered any musculoskeletal injury, e.g. ligament strain, tendon or muscle injury or fractures (broken bones)?(Required)

Please provide details if relevent

Any 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)

Please provide details if relevent

Other Medical Conditions(Required)

If other, please specify