Sign Up for Boot Camp Fields marked with * are mandatory. PRE-SCREEN QUESTIONNAIRE Training Session Selection *Parramatta - Mon/Wed/Fri - 6:00amParramatta - Mon/Wed/Fri - 6:45amParramatta - Mon/Wed/Fri - 9:30am (women)Parramatta - Mon/Wed/Fri - 5:00pmParramatta - Mon/Wed/Fri - 6:00pmParramatta - Mon/Tue/Thu - 7:30pmParramatta - Tue/Thu/Sat - 6:00pm (Sat 7:00am)Parramatta L.I.F.E Class - Mon/Tue/Thu - 6:30pm How did you hear about Rush Hour Australia? Please write the names and details of two other people that may wish to join Name: Mobile Number: Name: Mobile Number: PERSONAL DETAILS Title *: Name *: Surname *: Date of Birth*: Address *: Suburb *: Postcode *: Home Phone: Work Phone: Mobile *: Email *: Health Fund: Occupation: Full Time Part Time Casual EMERGENCY CONTACT DETAILS Name *: Phone *: Please note that completing this section will allow us to serve your needs better. EXCERCISE HISTORY Are you presently exercising? If Yes What type of exercise? How many times per week? How long have you been doing this? Have you been consistent? If Yes, how can Rush Hour Australia help? If No, describe what may be preventing you from doing so. If No Have you exercised in the past? If Yes, what was it you did? For How long? How many times per week? How long did you stick with it? Did you receive the results you wanted? If you did, why did you stop? If you did not, what do you think stopped you? RESULTS What results do you want to achieve? Flexibility Re-Shaping Body Weight Gain Improve Posture Stress Management Reduce Blood Pressure Power Sleep Better Improve Self Esteem Tone Up Lower % Body Fat Speed Sport Other On a scale of 1 – 10, how important is it to achieve these goals? What date would you like to achieve these goals by? What do you think caused you to be in the current physical shape that you are in? Junk Food Skipping Breakfast Alcohol Big Dinners Late at night Soft Drink Big Meals Eating Take Away Food Regularly Other Has any of the following stopped you from starting sooner? Work Injury Transport Motivation Money Family Time Is this still a Problem? RUSH 360 Would you be interested in finding out more about Rush Hour Australia Personal training services? Have you ever employed a personal trainer in the past? What did you like most about them / their training methods? What did you dislike most about them / their training methods? What is important for you to get from your personal trainer? All Below Fields are MANDATORY MEDICAL HISTORY Do you suffer or have you ever suffered from any injury, illness or other condition that may affect your ability to exercise, be aggravated by exercise or otherwise affect your training? Arthritis Asthma Diabetes Epilepsy Back Pain Heart Condition A Hernia Obesity Anxiety Liver / Kidney Conditions Recently Hospitalised Heart Palpitations Any Major Injuries Depression High Cholesterol Regular Headaches Chronic Cough Muscular Pain or Cramps High / Low Blood Pressure Pregnant? Family History of Heart Disease Family History of Stroke Any Infections / Infectious diseases Pain or Tightness in Chest Other If you answered yes to any of the above or identified a condition in the “Others” box: Which of the above have you suffered for a period of 6 months or so? You must have a clearance from your Doctor to join Rush Hour Australia. Do you have clearance from your Doctor to exercise? Are you seeing a heath professional to treat the condition? Can we talk to you about some of your options for treatment? DID YOU KNOW? Rush Hour Australia offers a complimentary nutritional seminar every 6 week Boot Camp cycle. Rush Hour Australia holds a complimentary boxing demonstration every 6 week Boot Camp cycle. Rush Hour Australia offers remedial massages with Health Fund Rebates. Rush Hour Australia offers personal training services at great rates. From $30.00 Rush Hour Australia offers tailored nutritional eating plans. From $50.00 Rush Hour Australia exclusively offers complimentary Healthy Tips and Recipes for all our website members. Join Rush Hour Australia on Facebook for the latest updates and tips. Visit www.facebook.com/RushHourAust I AGREE to the Terms and Conditions *: Digital Signature
