Intake Form

    Any information disclosed within this document will be held in confidence by Uthrive Athletic and details will not be disclosed with your GP or any other healthcare professional without your prior consent. This document is intended to aid the partners and/or contractors of Uthrive Athletic in compiling an exercise program tailored to your individual needs and to identify any possible problems or contraindications which may affect physical exercise. Your full disclosure is essential in order for us to ensure your exercise program is both as effective and safe as possible.

    Has your GP ever informed you that you may have a Coronary Heart Condition or are at risk of suffering a Stroke?
    Do you or have you ever had unexplained pains in your chest?
    Are you or have you ever received treatment for epilepsy?
    Have you ever been diagnosed as diabetic?
    Has your GP ever informed you that your blood pressure was too high?
    Are you pregnant?
    Are you currently taking any medication prescribed by your GP?
    Are you over 55 and unaccustomed to exercise?
    Has your GP ever informed you that you may have a bone, joint, ligament, cartage or muscle problem that might be exasperated by exercise?
    Do you have any muscle or joint pain that your trainer should be aware of?
    If yes do these issues effect you on a daily basis?
    Have you ever had or are you currently awaiting any major surgeries?
    Do you have any allergies?

    All information disclosed within this document is correct to the best of my knowledge and belief at the time of completion. I also understand that this information will be used in order to create a safe and effective exercise program tailored to my current health status.

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