Your Title (required)

First Name

Last Name

Gender
—Please choose an option—MaleFemaleTransgenderGender NeutralNon-binaryOther

If you are under 16 years of age, please enter your Parent/Guardian's name below, and their email and phone number in the following fields.

Parent/Guardian Name (If a minor)

Street Address

Suburb

Postcode

Your Email (required)

Your Telephone No (required)

Date of Birth - If you have trouble, try YYYY/MM/DD

Any other Injury Problems not previously mentioned - Describe

Anything else you wish to add.

Pre-Exercise Risk Screening Questionnaire

This questionnaire does not provide advice. Nor does it substitute for advice from an appropriately qualified medical professional. John Toomey and Wide Awake Wellness Pty Ltd gives no warranty of safety resulting from its use. The use of this pre-screening questionnaire in no way guarantees or safeguards against any injury or death sustained as a consequence of undertaking activities in our exercise sessions. No responsibility or liability whatsoever can be accepted by Wide Awake Wellness Pty Ltd or John Toomey for any loss, damage, illness, injury or death that may arise from any person acting on any statement or information contained in this document.

AIM: to identify those individuals with a known disease, or signs or symptoms of disease, who may be at a higher risk of an adverse event during physical activity/exercise. This checklist is self-administered and self-evaluated.

1. Have you ever suffered or been told by a doctor that you have suffered a stroke?
YesNo
2. Has your doctor ever told you that you have a heart condition?
YesNo
3. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
YesNo
4. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
YesNo
5. Have you had an asthma attack requiring medical attention at any time over the last 12 months?
YesNo
6. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
YesNo
7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
YesNo
8. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
YesNo

Any additional comments or relevant information:
IF YOU ANSWERED ‘YES’ to any of the Questions 1 -8 please consult a GP or appropriate Allied Health Professional to seek clearance/ approval to participate in these running groups. If a future change in your health, medical or physical capacity would lead you to respond Yes to any of the Questions 1-8, please consult your GP or Allied Health Professional before participating further in these running groups.

By choosing to Click "Send" you attest that all information provided above is true and correct.

Once you submit this form, we will send you an invoice for the sessions and your payment will guarantee your place in the sessions.