About
Health Coaching
Aqua Fitness
Services
1 on 1/Online Training
Registration
Aqua Fitness Registration Form
Consultation/Registration Form
Health Coaching Program Registration Form
BOOKINGS
About
Health Coaching
Aqua Fitness
Services
1 on 1/Online Training
Registration
Aqua Fitness Registration Form
Consultation/Registration Form
Health Coaching Program Registration Form
BOOKINGS
Consultation/Registration Form
Registration Form
Name
*
First Name
Last Name
Email Address
*
Date of Birth
*
MM
DD
YYYY
Age
*
Sex
*
Male
Female
Other
Address
*
Phone
*
e.g. +1 868 123 4567
Country
(###)
###
####
Name of Emergency Contact
Relationship to Emergency Contact
Emergency Contact Phone
e.g. +1 868 123 4567
Country
(###)
###
####
Occupation
What conditions? (if any)
*
Please select the check box, if you have been or are currently suffering from any of the following conditions:
Allergies
Arthritis/Bursitis
Asthma
Autoimmune Disease
Back Problems
Bad Knees
Cancer
Diabetes
Injury from accident
Joint Problems
Recent birth
Lung disease
Pregnant
Resting heart-rate
Heart Disease
Recent surgery
High blood pressure
Orthopedic problems
Recent hospitalization
None of the above
Are you under any medication that the instructor or staff should be aware of? Please mention below:
*
Physicians Name
Physicians Phone Number
Reasons for Registering
Please state very clearly, your reasons for consultation or personal training.
Please state your covid 19 vaccine status, brand and number of doses.
*
Date of Last Doctor's CheckUp
MM
DD
YYYY
Do you take any medication on a regular basis?
*
Yes
No
If yes, please list medication and reasons for taking
Have you recently been hospitalized?
*
Yes
No
If yes, please explain
Do you:
*
Smoke?
Have high blood pressure?
Have high cholesterol?
None of the above
Have you, your parents, or siblings who prior to age 55 had a:
*
HEART ATTACK
STROKE
HIGH BLOOD PRESSURE
HIGH CHOLESTEROL
HAVE KNOWN HEART DISEASE
RHEUMATIC HEART DISEASE
HEART MURMUR
CHEST PAIN WITH EXERTION
IRREGULAR HEART BEAT OR PALPITATIONS
LIGHTHEADEDNESS OR FAINTING
EMPHYSEMA
OTHER METABOLIC DISORDERS (Thyroid, kidney, etc)
EPILEPSY
ASTHMA
BACK PAIN: UPPER- MIDDLE- LOWER
None of the above
Any Muscle Pain or Injury? If yes, explain
*
Any other joint pain? If yes, explain
*
Do you confirm the above is true and correct?
*
Yes, I confirm
How did you learn of Chetwayo's Fitness Enterprise?
*
TV
Radio
Social Media ads
Newspaper ads
Family/Friend
Other
Disclaimer
*
The disclaimer is listed in the yellow button below.
I agree that that I have read and understand the contents of the Disclaimer stated on this website.
Today's Date
*
MM
DD
YYYY
Thank you for choosing Chetwayo’s Fitness Enterprise!
Important Disclaimer
*Credit Card/ Online Payment Available*
