Pre-Exercise Screening

A compulsory questionnaire to be completed for participation in any of our Thrive classes and Assessments.

First Name *

Last Name *

Mobile Number *

Email Address *

Date of Birth (DD/MM/YYYY) *

Address

Street address

City

State

Postcode

1. Has your medical practitioner ever told you that you have a heart condition, or have you ever suffered a stroke? *

YesNo

2. Do you experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise? *

YesNo

3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise? *

YesNo

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? *

YesNo

5. If you have diabetes (Type 1 or 2), have you had trouble controlling your blood sugar (glucose) in the last 3 months? *

YesNoN/A

6. Do you have any other conditions that may require special consideration for you to exercise? *

YesNo

7. If so, list any such conditions here.

8. Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities (Light, Moderate, Vigorous/High). *

9. Do you have a family history of heart disease (e.g., stroke, heart attack)? If so, state their relationship to you and their age at the time of the heart disease event. *

10. Do you smoke cigarettes on a daily or weekly basis, or have you quit smoking in the last 6 months? If currently smoking, how many per day or week? *

11. Please provide an estimate of your height and current weight. *

12. Have you been told that you have high blood pressure? If yes, are you taking any medication for this condition? Please provide details. *

13. Have you been told that you have high cholesterol/blood lipids? If yes, are you taking any medication for this condition? Please provide details. *

14. Have you been told that you have high blood sugar (glucose)? If yes, are you taking any medication for this condition? Please provide details. *

15. Are you currently taking prescribed medication(s) for any condition(s) additional to those already stated? If yes, please provide details. *

16. Have you spent time in hospital (including day admission) for any condition/illness/injury during the last 12 months? If yes, provide details. *

17. Are you pregnant or have you given birth within the last 12 months? If yes, provide details. (Please enter "N/A" if not applicable). *

18. Do you have any diagnosed muscle, bone, tendon, ligament or joint problems that you have been told could be made worse by participating in exercise? If yes, provide details. *

19. Do you have any goals/are there any areas specifically you wish to work on? *

20. Is there anything else you would like us to be made aware of? *

21. How did you hear about us? *

Participant Waiver, Release, and Assumption of Risk

Thrive by Total Physiotherapy (Thrive)

Location: 225 Clovelly Road, Clovelly, NSW, 2031

Effective Date: 22/01/2025

Participant Waiver, Release, and Assumption of Risk

By signing this document, I acknowledge and agree to the following terms and conditions regarding my participation in the services provided by Thrive, including but not limited to physiotherapy sessions, Physiotherapist and Personal Trainer-led group exercise classes, and physical assessments (collectively referred to as “Activities”).

1. Acknowledgment of Risks

1.1 I understand that participation in the Activities involves inherent risks, including but not limited to:

• Physical exertion, which may lead to injury, pain, or discomfort.

• Use of equipment.

• Risk of aggravation of pre-existing conditions or injuries.

1.2 I confirm that I have disclosed any relevant medical conditions, injuries, or limitations to Thrive prior to participation in the Activities.

1.3 I understand that while Thrive takes all reasonable steps to ensure the safety of its participants, injuries or unforeseen incidents may occur, and I voluntarily assume all associated risks.

2. Waiver of Liability

2.1 To the extent permitted by law, I release, waive, and discharge Thrive, its directors, employees, contractors (including physiotherapists and personal trainers), and agents from any and all claims, liabilities, or demands arising from:

• Injuries, losses, or damages sustained during participation in the Activities.

• Negligence (excluding gross negligence or willful misconduct) by Thrive or its representatives.

2.2 I acknowledge that this waiver does not exclude liability for personal injury or death caused by the negligence of Thrive as outlined in section 5N of the Civil Liability Act 2002 (NSW) and relevant provisions of the ACL.

3. Medical Clearance and Fitness to Participate

3.1 I confirm that:

• I am in good physical health and do not have any condition that would prevent safe participation in the Activities.

• I have sought medical advice where necessary and will notify Thrive of any changes to my health or fitness.

3.2 In the event of an emergency, I consent to Thrive seeking medical assistance on my behalf. I agree to be responsible for any associated costs.

4. Indemnity

4.1 I agree to indemnify and hold harmless Thrive, its directors, employees, contractors, and agents from any claims, costs, or damages (including legal fees) arising out of my participation in the Activities or my failure to comply with this waiver.

5. Consent to Photography and Media Use

5.1 At times, a representative of Thrive may take photos or videos to use for Promotional Material. You will always be asked if you Consent to being included in the Material, and you can Consent or Withdraw Consent at any time by providing verbal or written advice.

6. Governing Law

6.1 This agreement is governed by the laws of New South Wales, Australia, and any disputes will be subject to the exclusive jurisdiction of the courts in Sydney, NSW.

Acknowledgment and Signature

By signing below, I confirm that:

• I have read and understood this waiver in its entirety.

• I voluntarily agree to the terms and conditions outlined above.

• I am over 18 years of age or have obtained parental/guardian consent if under 18.

Signature *

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Date *

If under 18 - Signature of Parent or Guardian

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Total Physiotherapy & Thrive are businesses of McKay Physiotherapy Pty Ltd

ABN: 40366168324

228c Clovelly Road, Coogee, NSW Australia 2034

Phone: (02) 8322 3898