General Information

Name *

Date Of Birth *

Email *

Mobile Phone *

Address *

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 *

Yes No

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.

Further details

Do you have any pain / complaint in the following areas *

Yes No

Feet, Ankles, Lower leg, Knees, Upper legs, Hips, Back, Shoulders, Neck, Head, Elbows, Hands or anywhere else?

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.

Full name (typed signature) *

Type your full name to sign this declaration.

Medical Screening Form

DECLARATION

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