Pre Exercise Health Screening Form - Australian Institute of Martial Arts

PEHS Form

This is the Pre-Exercise Health Screening Form Page. If you need to update your previous submission or add a group member, this is the go to page, which will be visible when you login as a member and found under the Membership tab on the menu.

You have chosen the link to this page for either adding an additional group membership member or updating your existing PEHS Form submission with your new health and medical conditions information. You can add as many forms required for your group membership, remember every member must fill out this form independently.

As previously, Admin will assess and approve your registration within 24 hrs of submission, if you do not hear from us or do not receive confirmation of approval for your registration, please call AIMA directly. Contact Us

Before any member can participate in any class whether its a membership or free trial class, each member is required to fill out the PEHS Form. If you are a group membership, each group member is required to fill out their own form sign and submit it, however minors need to have either their parents or guardians sign the form.

Once this form is submitted correctly and approved along with your registration, you are good to go.

Finally, then let us know when you would like to attend your free trial and we will make it all happen for you. 🙂

Pre-Exercise Health Screening

Please Fill Out The PEHS Form and Submit

Participating Member's First and Last Name*
Please note each member of a group membership must fill out their own PEHS Form
If you are participating in our Boxing or Kickboxing Classes, do you have your own Boxing Gloves to bring to Class?*
Date of Birth*
Age*
Gender*
Address*
Street Address Suburb/ City State / Province / Region ZIP / Postal Code Country
Mobile*
Email*
Enter Email Confirm Email
Emergency Contact Ph*
Name*
Relationship*
Please describe all areas you frequently experience pain or discomfort?*
What is your Occupation?*
If you are not working or you are retired, please answer as Not Working or Retired for your Occupation.
What aggravates pain?*
What alleviates pain?*
Pain Scale*
1. Have you recently experienced unusual spinal, joint or muscular pain?*
2. Has your Doctor ever told you that you have a heart condition or have you ever suffered a stroke?*
3. Do you ever experience unexplained pains in your chest at rest or during physical activity / exercise?*
4. Do you ever feel faint or have spells of dizziness during exercises that cuases you to lose balance?*
5. Have you had an Asthma Attack requiring immediate medical attention at any time in the last 12 months?*
6. If you have Diabetes Type I or Type II, have you had trouble controlling your blood glucose levels over the last 3 months?*
7. Do you have any diagnosed muscle, bone or joint problems that you have been told that could be made worse by participating in physical exercise?*
8. Have you had any major or recent surgery within past 12 months?*
9. Are you currently take any medication?*
10. Do you have any other medical conditions or injuries that we should be aware of, or any conditions that may make it dangerous for you to participate in physical activity?*
This Questionnaire is self administered and self-evaluated. Ausrtralian Institute Martial Arts does not accept any responsibility or liability whatsoever for any loss, damage, illness, injury or death that may arise from a person acting on any statement or information contained in this tool.

IF YOU ANSWERED "YES" to any of these 10 questions, you are required to obtain written medical clearance / approval from your GP or appropriate allied health professional prior to undertaking physical activity / exercise with us
I believe that to the best of my knowledge the information I have supplied is correct. I understand that I must inform the trainer of any medical conditions that may prevent me from exercising or may cause injury prior to commencing training. I understand that it is my responsibility to inform you of any changes in my medical or physical condition. I am aware that the trainer will do everything to ensure that my exercise program is safe and effective. However I am choosing to exercise at my own risk and Australian Institute of Martial Arts does not take responsibility for any personal injury or liability.
Date*
DD slash MM slash YYYY

This date acknowledges the day you or the parent or guardian filled out the form, signed and agreed to the conditions of the form, which could be on the same day as your membership registration or anytime before or after.
Your Signature*
Please note you must be 18 years of age or older to validate and sign this form.
Full Name of Participating Member or Parent/ Guardian if Applicable*
If the participant member is over 18 years of age and signing this form instead of a parent or guardian, please fill out all your personal details again in this and the next fields as these fields are also set as a required fields and will need to be completed before this form can be submitted. Thank you
INDEMNITY & RELEASE CONSENT FORM

Agreement for participating in Personal / Group Strength, Fitness, Conditioning and Martial Arts training. The “Trainer” refers to “Australian Institute of Martial Arts”. “Activity” refers to the participation in personal / group strength, fitness, gymnastic type and martial arts conditioning training, sporting activities and general advices.
• The information obtained in this document will be treated as privileged and confidential.
• I acknowledge that it is a condition of participating in this activity that I do so at my own risk’
• I accept all risks and hereby indemnify and release the trainer, their agents, affiliates, employees, members, sponsors, promoters and any person or body directly and indirectly associated with the trainer or program, against all liability (including liability for their negligence and the negligence of others) claims, damage, loss or injury (including death) demands and proceedings arising out of or connected with my participation in this.
• This release and indemnity continues forever and binds my heirs, successors, executors, personal representatives and restricts me from suing or otherwise claiming against the Trainer, presently or at any future time, for damage, loss or injury that may occur to myself or my property as a result of participating in this activity
• I acknowledge that participating in this activity may involve a risk of serious injury or even death from various causes including: over exertion, dehydration, equipment failure and accidents with equipment and surroundings.
• I recognise the difficulties associated with the activity and attest I am physically fit to participate safely in the activity and that a qualified medical practitioner has not advised me otherwise.
• I understand the demanding physical nature of this activity. I am not aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in this activity. In the event that I become aware of any medical condition, injury or impairment that may be detrimental to my health if I participate in this activity my Trainer will be immediately informed. By continuing to participate in this activity, I accept the risks despite these conditions and still, and will always be under the terms of this agreement.
• I am voluntarily executing this release and would not otherwise be permitted to participate in this activity, I have been granted the opportunity to seek independent legal advice before executing this release.
• Any questions that I may have had have been answered to my satisfaction. I understand that I am free to withdraw from this program at any time I desire, subject to the terms and conditions of my membership agreement.
• I certify that I am 18 years or older and have read this document and fully understand it or as a parent or guardian of the participant, I agree to the above for myself and on behalf of the participant and I indemnify and will keep indemnified any person or body directly or indirectly associated with the conduct of the activity or the terms referred to.
Date*
DD slash MM slash YYYY

This date acknowledges the day you or the parent or guardian filled out the form, signed and agreed to the conditions of the form, which could be on the same day as your membership registration or anytime before or after.
Your Signature*
Full Name of Participating Member or Parent/ Guardian if Applicable*
If the participant member is over 18 years of age and signing this form instead of a parent or guardian, please fill out all your personal details again in this and the next fields as these fields are also set as a required fields and will need to be completed before this form can be submitted. Thank you
Address of Participating Member or Parent/ Guardian if Applicable*
Street Address Suburb/ City State / Province / Region ZIP / Postal Code Country
Mobile*
Email*
Enter Email Confirm Email
Date*
DD slash MM slash YYYY

This date acknowledges the day you or the parent or guardian filled out the form, signed and agreed to the conditions of the form, which could be on the same day as your membership registration or anytime before or after.