Memberships

PLEASE PROVIDE ALL THE INFORMATION BELOW:

1. PERSONAL INFORMATION:
Name Surname
Gender
Male
Female
Date of Birth
Cell Phone Number Home Phone Number
Email Address
Local Address Postal Code
PSI Membership Selected
Please Note: That you hereby accept and bind yourself to the full contract period.
Commencement Date

2. WORK INFO DETAILS:
Are you presently employed?
Yes
No
Company Name Occupation / Job
What is your present occupational position?
Work Phone Number

3. IN CASE OF EMERGENCY:
Name Relationship
Cell Phone Number Work Phone Number

4. PERSONAL PHYSICIAN (HOUSE DOCTOR):
Name
Phone Number Fax Number

5. PAST / PRESENT HISTORY:
Have you had OR do you presently have any of the following conditions? (Check if yes)
Rheumatic Fever
Recent Operation
Oedema (swelling of ankles)
High Blood Pressure
Injury to back or knees
Low Blood Pressure
Seizures
Lung Disease
Heart Attack
Fainting or dizziness with or without physical exertion
Diabetes
High Cholesterol
Chest Pains
Orthopnoea (the need to sit up to breath comfortably) or Paroxysmal (sudden, unexpected attack
Nocturnal Dyspnoea (shortness of breath at night)
Shortness of breath at rest or with mild exertion
Palpitations or Tachycardia (unusally strong or rapid heartbeat)
Intermittent Claudication (calf cramping)
Pain or discomfort in the chest, neck, jaw, arms or other areas with or without physical exertion
Known Heart Murmur
Unusual fatigue or shortness of breath with usual activities
Temporary loss of visual acuity or speech, or short-term numbness or weakness in one side, arm or leg of the body
Other
Explain checked items:

6. FAMILY HISTORY:
Have any of your first-degree relatives (parent, sibling or child) experienced the following conditions?
(Check if yes) In addition, please identify at what age the condition occured.
Age:
Heart Arrhythmia
Age:
Heart Attack
Age:
Heart Operation
Age:
Congenital Heart Disease
Age:
Significant disability
secondary to a
heart condition
Age:
High Blood Pressure
Age:
High Cholesterol
Age:
Diabetes
Age:
Marfan Syndrome
Age:
Premature death before age 50
Age:
Other major illness
Explain checked items:

7. ACTIVITY HISTORY:
1. How were you referred to this program / institute? (Please be specific)
2. Why are you enrolling in this program? (Please be specific)
3. Have you ever worked with a personal trainer before?
Yes
No
4. Date of your last physical examination performed by a physician:
5. Do you participate in a regular exercise program at this time?
Yes
No
If yes, briefly describe:
6. Can you currently walk 2 km briskly without fatigue?
Yes
No
7. Have you ever performed resistance training exercises in the past?
Yes
No
8. Do you have injuries (bone or muscle disabilities) that may interfere with exercising?
Yes
No
If yes, briefly describe:
9. Do you smoke?
Yes
No
If yes, how much per day? If yes, what was your age when you started?
10. What is your body weight now?
What was it one year ago?
What was it at age 21?
11. Do you follow or have you recently followed any specific dietary intake plan, and in general how do you feel about your nutritional habits?
12. List the medications you are presently taking.
13. List in order your personal health and fitness objectives.
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