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Four Peak Pre-Screening

This form will help assess the suitability for all CHNZ members when being referred to the Optimal Growth Program.

First name

Last name

Date of Birth

Phone Number

Email

Medical History:

Do you currently have, or have you had any of the following conditions?

Heart disease

High blood pressure

Diabetes

Heart disease

Respiratory conditions (e.g., asthma)

Musculoskeletal disorders (e.g., arthritis, back pain)

Mental health conditions

Medications: List any medications you are currently taking.

Allergies: Any known allergies (foods, medications, environmental).

Surgeries: Describe any major surgeries you have undergone

Injuries: Recent or past injuries that might affect exercise.

Current Physical Activity Level:

Sedentary

Light (e.g., walking, stretching)

Moderate (e.g., jogging, swimming)

High (e.g., competitive sports, intense training)

Drinking or Smoking:

Yes

No

Describe your typical diet (e.g., balanced, vegetarian, high in processed foods).

Type of Exercise Preferred: - Cardio - Strength Training - Flexibility - Yoga/Pilates - Other (specify)

What are your fitness goals? (Weight loss, muscle gain, general health, specific sport performance, etc.)

Experience Level:

Beginner

Intermediate

Advanced

Psychological/Emotional Health:

Stress Levels: Rate from 1-10 (1 being very low, 10 being very high)

Are you currently under emotional or psychological stress? If yes, please describe.

Emergency Contact Name & Relationship:

Emergency Contact Phone Number

Consent and Waiver:

By signing below, I confirm that I have read and understood the questions above and have answered them truthfully. I recognize that this information is essential in the process of offering the Optimal Growth Program with Community Health NZ's Four Peak Fitness.

I understand that participating in fitness activities involves inherent risks. I accept full responsibility for my safety and agree to follow all guidance provided by the staff. I release Community Health NZ, its employees, trainers, and representatives from any liability for injury, illness, or adverse outcomes arising from my participation, except in cases of proven negligence.

I commit to participating with care for my health and safety.

Your Signature

Thanks for submitting!

Fully equipped Gym Fitness Facility

Located at 172 Talbot Street, Geraldine, NZ

Staffed Hours 10am - 2pm Monday - Friday

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