Please complete all required fields!
Regular exercise is fun and healthy. For most people, it is safe to increase physical activity. In some cases, it is advisable to consult your doctor before starting. This form is about to find out if you can start training right away, or if you should speak to your doctor first.
This questionnaire is valid for persons between 15 and 69 years. If you are over 69 years of age and are not used to exercise regularly, be sure to speak to your doctor before you start exercising.
Answer the following questions thoroughly. Please read the questions carefully and answer each question honestly with yes or no.
Before we start, we need some information to be able to assign the questionnaire to the right person.
The same address you used to register with us.
Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/or that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Do you suffer from respiratory problems (for example, asthma, bronchitis)?
Do you have severe back problems, such as a herniated disc?
Are you currently under treatment by a physiotherapist?
Because of personal experience or medical advice, are you aware of another reason that could prevent you from doing sports without medical supervision?
Thank you for taking the time to complete the questionnaire. What's next? After you have sent the survey, we will check it and contact you by email. Usually, this takes only a few minutes.
Please talk to your doctor about your intention to become more active. Inform him about this questionnaire and which question(s) you answered with "yes". We'll email you a copy of your answers. Anyways, please submit the form so that we can mark your account accurately and get in touch with you in a proactive manner if necessary.
I have voluntarily chosen to participate in the training program offered by MOVE YOUR ASS Personal Training. I have answered the questions above to the best of my ability and affirm that my physical condition is good, and I have no known conditions that would prevent me from participation. I acknowledge that participation is at my own pace and comfort level and that I may discontinue my participation at any time. Furthermore, I agree to self-determine my exertion through sound judgment and to stop any activity that exceeds my limitations. I understand that by accepting this agreement that I hereby waive and release MOVE YOUR ASS Personal Training, its Board Members, staff, and all relevant employees in any way from liabilities or demands as a result of injury, loss, or adverse health conditions as a result of my participation.
MOVE YOUR ASS Personal Training
Moserstrasse 18 CH-3014 Bern
+41 32 510 38 70