Pre-Health Screen

Required field

Consent
DD slash MM slash YYYY
1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?*
2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?*
3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?*
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*
5. If you have diabetes (type I or II ) have you had trouble controlling your blood glucose in the last 3 months?*
6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?*
7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?*
IF YOU ANSWERED 'YES' to any of the 7 questions, you will need to see one of our gym instructors before undertaking physical activity/ exercise. IF YOU ANSWERED 'NO' to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/ exercise.
I believe that to the best of my knowledge, all of the information I have supplied within this form is correct. I also declare that to my knowledge, I am currently of sound health and have no pre-existing medical conditions that I am aware of that would preclude me from using the gym component of my membership without causing harm to myself or others.*
Signature*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.