Pre-Health Screen

Required field

1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?*
2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?*
3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?*
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 1 or 2) have you had trouble controlling your blood sugar (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 this membership without causing harm to myself or others.*
This screening form does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from it's use. The screening system is no way guaranteed against injury or death. No responsibility or liability whatsoever can be accepted by the City of Swan for any loss, damage or injury that may arise from any person acting on any statement or information contained in this form.*
This field is for validation purposes and should be left unchanged.