Health questionnarie

* Indicates required field

Client Name*

Client Email*

Date of Birth*

Phone Number*

Regular physical activity is fun and healthy. and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However. some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age. and you are not used to being very active, check with your doctor. Please read each question carefully and answer honestly by circling YES or NO.

Has your doctor ever said 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 a chest pain when you were not doing physical activity?*

YES

NO

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

YES

NO

Do you have a bone or joint problem (for example back. knee or hip) that could be made worse by a change in your physical activity?*

YES

NO

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

YES

NO

Do you know of any other reason why you should not take part in physical activity?*

YES

NO

If you answered YES to the previous question please comment:

If you answered YES to one or more questions: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.

If you answered NO to one or more questions: it is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A ﬁtness appraisal can help determine your ability levels.

I have read, understood and accurately completed this questionnaire. I conﬁrm that I am voluntarily engaging in an acceptable level of exercise and my participation involves a risk of injury.

Check this box to acknowledge the above

*

Confirm the date*

Declaration

In consideration of being allowed to participate in the activities and programmes at ST-FIT, l acknowledge that:

1. I am aware of and understand the potential risks and dangers associated with physical activity including the use of equipment and I am voluntarily participating in these activities with knowledge of the risks and dangers involved.

2. I understand that exercise and fitness activities in and outdoors involve a risk of injury and even death and that I am voluntarily participating in these activities and using equipment and facilities with knowledge of the dangers involved. I hereby agree and expressly assume all and any risks of injury or death.

3. I know of no reason why i should not participate in any of the programmes and activities with ST—FIT. I hereby declare myself free of any condition, disease, infirmity or illness that may affect my participation. i agree to inform a member of staff and where appropriate provide written consent from my doctor should such a condition or complaint arise before continuing with any activity.

4. l agree to abide by all oral notices regarding safety whilst at a ST-FIT class. I am aware I have the opportunity to ask questions about the activities, general use of equipment and other related issues at class. If I choose not to take the advice or to disregard any advice given, I do so voluntarily and accept liability for all resulting injuries or damage.

5. I do hereby waive, release and discharge ST—FIT from any and all responsibility or liability for injuries or damages resulting from my participation in any activities or my use of equipment or facilities in the above- mentioned activities.

6. This questionnaire has been completed accurately to the best of my knowledge and belief. I have read, understood and completed this questionnaire and agree to be bound by its conditions.

I agree to the declaration above in full

*

Quick Links

Location

Pure Gym

Leeds City Centre North

Merrion Way

LS2 8BT

View on map ↗

Health questionnarie

Quick Links

Location

Social