CPD-BCI-02-REGISTRATION-PARQ

You must first complete CPD-BCI-01-WELCOME before viewing this Lesson

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PLEASE COMPLETE THIS FORM

This MUST be completed and submitted as accurately and concisely as possible BEFORE you attend the live training day. Once you have hit ‘submit’, please continue to the quiz at the bottom of the page to move forward.

Step 1 of 2

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Date of Birth*
Date Format: DD slash MM slash YYYY
Next of Kin Name*
Next of Kin Contact Number*
Doctor Name*
Doctor Surgery / Contact*
What is your Estimated Height? CM / M / Ft&In*
What is your Estimated Weight? KG / Lbs / ST & Lbs*
What is your blood type?*
What is your Current Occupational Activity Level?*
01 - Inactive 02 - most professionals, office workers, shop workers, teachers, homemakers 03 - workers in light industry, most farm workers, active students, department store workers, soldiers not in active duty, commercial fishing workers 04 - full time athletes and dancers, unskilled labourers, forestry workers, military recruits and soldiers in active service, mine workers, steel workers 05 - lumberjacks, blacksmiths, females construction workers
What is your Current Additional Activity Level?*
01 - Inactive 02 - Moderate intensity activity less than 5 x week for 30 minutes 03 - Moderate intensity activity for 5-7 x / week for 30 minutes 04 - Vigorous intensity activity for 5+ x / week for up to 60 minutes 05 - Vigorous intensity activity for 5+ x / week for up to more 1-2 hours or more per day
What is your Ethnic / Racial Classification?*
Medical History & Health Questions
Have you suffered or do you currently suffer from any cardiovascular, respiratory, neurological, musculoskeletal or metabolic disorders or diseases?*
Is there any family history of cancer, cardiovascular disease, diabetes or any conditions?
Are you currently on any medication?
Have you have been under a general anesthetic within the last 5 years?
Have you been prescribed antibiotics for any reason? (if so, please state how many courses you have undertaken and what the latest 2 courses were for)
Please state any known allergies/sensitivities/intolerances you may have to any foods or food supplements?
Have you ever been advised by a physician or health practitioner to avoid any type of exercise, food or supplement?
Is there any reason not already mentioned why it may be unsuitable for you to exercise, or participate in certain types of exercise?
Goals & Objectives
Please list your Primary Goals in order of importance & time scales if appropriate. Please be as detailed as possible.*
Where are you now in relation to your goals?*
What barriers may prevent you from attaining your goals?*
What things would you be willing to sacrifice or undertake to help you reach your goals?*

Lifestyle
What is the heaviest you've ever weighed? (and how old were you at the time?)*
What do you think is your 'Ideal Weight'?
Do you walk?*
(or do some other moderate intensity activity that raises your heart rate and breathing rate) for 30 minutes at least 5 times per week? Please give details such as mode, duration, intensity & frequency
Do you run?*
(or do some other vigorous intensity activity that significantly raises your heart rate and breathing rate) for 20 minutes at least 3 times per week? Please give details such as how long you have been training, the mode, duration, intensity & frequency)
Do you lift?
Do you currently or have previously undertaken resistance training? Please give details such as how long you have been training, the exercises, types of training, intensity (reps), volume (sets) & frequency
How do you usually get around (car, walking, bike etc)? And how much time per day do you usually spend in this mode of transport
Is there anything that can reduce your weekly activity levels? such as family or work commitments
What causes of stress do you have in your life?
How do you handle stress?
How many units of Alcohol do you consume?
How many units of alcohol on average do you estimate you consume each week? A unit of alcohol is roughly equivalent to half a pint of beer, cider or lager, a 25ml (pub) measure of spirit such as vodka, whisky or gin, a 50ml (pub) measure of fortified wine such as port or sherry, or a small (125ml) glass of wine.
Is this consumption spread across the week or more at a particular time? if so, when?
Do you smoke? (if the answer is no, please skip to the sleep questions)
If you answered yes, How much do you smoke per week?
If you answered yes, How long have you smoked for?
Are you considering giving up?
I agree that Marc Edwards Fitness & Representatives' are free of any/all liability for death, injury or health problem that may result from/be aggravated by my participation*
- Yes
I agree that Marc Edwards Fitness & Representatives' are free of any/all liability for death, injury or health problem that may result from/be aggravated by this training with 3rd parties*
- Yes
I understand that by signing this / completing this form that any use of excersises post course/workshop/session, I assume all responsibility for demonstrations and the safety of the end user (even if the end user is myself)*
- Yes
Marc Edwards Fitness and Representatives means anybody delivering a training session / Course / Workshop in association with / on behalf of Marc Edwards or Associated Training Provider (REPs Accredited or not) and any Training Session/Course/Class/Workshops including (but not limited to) any of the following names:

Marc Edwards Fitness / K5 Health and Fitness / Universal Training / Universal Fitness Training / Universal Martial Arts Training / Universal Personal Training / K500 Kickboxing / Jordan Fitness / WAKO GB

CPD-BCI-02-REGISTRATION-PARQ

PLEASE COMPLETE THIS FORM

Step 1 of 2

Medical History & Health Questions

Goals & Objectives

Lifestyle