Pre Memebership Medical | State Of Mind Fitness – Londons Boxing Gym

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Medical Screening Form

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General Information
Name*
First Last
Date Of Birth*
DD slash MM slash YYYY
Email*
Mobile Phone*
Address*
Street Address Address Line 2 City ZIP / Postal Code Country

Medical Information
Has your doctor ever advised you not to participate in physical activity without their recommendation ?*
- Yes
- No
Further details*
Do you suffer from, or have you suffered from any of the following conditions*
Angina, Heart attack, Other heart condition, Chest pains, Breathlessness, Stoke, Asthma, Diabetes, Epilepsy, Allergy, Dizziness, Loss of consciousness, Arthritis, Cholesterol problems, Blood pressure problems or Bronchial problems.
- Yes
- No
Further details*
Do you have any pain / complaint in the following areas*
Feet, Ankles, Lower leg, Knees, Upper legs, Hips, Back, Shoulders, Neck, Head, Elbows, Hands or anywhere else?
- Yes
- No
Further details*
Have you had any sprain or strain injury in the last 18 months?*
- Yes
- No
Further details*
Does exercise aggravate any condition or injury*
- Yes
- No
Further details*
Is your doctor currently prescribing you any medication?*
- Yes
- No
Further details*
Are you pregnant or have you given birth in the last 6 weeks?*
- Yes
- No
Do you know of any reason why you should not participate in any physical activity?*
- Yes
- No
Further details*

DECLARATION

I have read and understood the questions in this form and have answered them honestly and to the best of my knowledge.

I understand that if I have answered yes to any of the questions in this form then I will need to discuss the details with my personal trainer and may be asked to talk with my doctor before commencing a fitness programme.

I agree to inform my personal trainer should my health change so that I can answer yes to any of the above questions.
Signature*

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