Health Questionnaire 2023

Name *

First

Last

Email *

Date of Birth *

Address *

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes
No

Do you feel pain in your chest when you do physical activity? *

Yes
No

In the past month, have you had chest pain while you were NOT doing physical activity? *

Yes
No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes
No

Do you have a bone or joint problem that could be made worse by physical activity? *

Yes
No

Is your doctor currently prescribing drugs for your blood pressure or heart condition? *

Yes
No

Are you pregnant or recently had a baby? *

Yes
No

Have you had any recent injuries or operations? *

Yes
No

Do you know of any other reason why you should not do physical activity? *

Yes
No

If you have answered yes to any questions above, please give further details:

I agree that I am voluntarily participating in this membership. I agree to assume full responsibility for any injuries which I might incur as a result of participating sessions. I will monitor my own safety and fitness level. *

I agree

I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance training and stretching. I realise that my participation in these activities involves the risk of injury. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me. Please Note: If your health changes so that you then answer YES to any of the above questions, please let me know asap. *

I agree