Casual Visitor Form | CrossFit East Auckland

PERSONAL INFORMATION

Name*

Address*

Phone*

Mobile*

Gender*

Email*

Date of Birth*

Occupation*

Emergency Contact*

Emergency Number*

How did you hear about CFEA?*

Please select one age category*

Which location is most convenient for you?*

Do you have any previous CrossFit experience?*

Yes
No

please provide details for how long and at which facility.*

HEALTH ASSESSMENT

Have you ever had any form of heart disease?*

Have you ever experienced shortness of breath or chest pains?*

Do you have a family history of heart disease?*

Do you have high blood pressure?*

Do you have diabetes?*

Do you have any allergies?*

Are you currently taking any medication?*

Are you a smoker?*

Do you ever get dizzy?*

Are you currently exercising?*

Have you participated in strenuous exercise before?*

Are there any exercises that you know you cannot do?*

Is there any reason you know of that you should not participate in exercise?*

Do you have any current injuries?*

Do you have problems with your knees?*

Do you have problems with your back?*

Do you have any hip/pelvis problems?*

Do you have any neck / shoulder problems?*

If you answered yes to any of the questions above please provide detailed information below

Are there any other relevant medical details or other factors that we should be aware of? You are welcome to include feedback or suggestions also below

WARNING … Safety first!

High intensity exercise must be approached with caution in particular at the beginning. A gradual ramp-up of
intensity is necessary to allow muscles cells to adapt to the new demands being placed on them. Failure to do
increases the risk of a life threatening condition known as ‘Rhabdomyolysis’. In short the muscle cells are damaged
flooding the bloodstream with toxins that can overwhelm the kidneys as they attempt to cleanse the blood, leading
to potential shutdown. CrossFit can cause Rhabdomyolysis. It is important that you start at a reduced intensity.
Brown urine, complete muscle weakness and/or swelling of joints are warning signs of ‘Rhabdo’. If you develop these
symptoms, seek medical assistance IMMEDIATELY.