Registration for Chaz O'Loughlin Personal Training

Name *

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Mobile number

(###)

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Emergency Contact

First Name

Last Name

Emergency Contact Number

(###)

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How did you find out about Chaz O'Loughlin Personal Training

Active History

List any medical conditions you currently have or have had in the last five years. *

List any serious injuries you have had *

Please list any medications your are now taking *

Please list your health and fitness goals your are aiming to achieve.

I confirm that I have completed the above questionnaire to the best of my ability and that I have provided accurate information regarding my current health status. I take it upon myself to discuss and changes in my health with the trainer. I understand that any exercise program has certain risks. I understand that the degrees of risk depend on my health and physical fitness. I am voluntarily participating in the fitness program and will immediately discontinue any activity if I feel any symptoms of distress or discomfort and will notify my trainer. I understand that the trainer is not a health or Medical Practioner and therefore cannot diagnose or treat individual health or medical problems. All such concerns should be directed to my own General practitioner and I agree to do so.