Health Screening Form

Name

D.O.B

Address

Post Code

Email

example@example.com

Contact Number

For most people physical activity should not pose any problem or hazard. This Form has been designed to identify the small number of participants for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.

Please read them carefully and circle the yes or no opposite the question as it applies to you.

1. Have you ever be diagnosed with a heart or lung condition?*

if yes please provide details

2. Do you often feel faint or have spells of Dizziness?*

if yes please provide details

3. Have you been diagnosed with high Blood Pressure?*

if yes please provide details

4. Have you been diagnosed with Diabetes?*

5. Are you currently Pregnant or have given birth in the last 6 months*

6. Have you had an operation in the last 12 months*

if yes please provide details

7. Do you suffer from Epilepsy or seizures*

8. Have you been diagnosed with a bone or Joint problem?*

if yes please provide details

9. Is there any reason not mentioned above that could prevent you from exercising*

if yes please provide details

If you have answered NO to all questions

If you have answered these questions accurately, Please sign the declaration of health below but if any issues arise in the future please inform instructor ASAP and complete a new form.

If you have answered YES to one or more questions

Please speak to the instructor about your condition in more detail to help clarify, and to enable the instructor to advise on any adaptations that may be required for you to continue doing physical activity or if you need to seek medical clearance.

Delay becoming much more active if:

You are not feeling well because of a temporary illness such as a cold or a fever wait until you feel better; or you are pregnant talk to your doctoror midwifebefore you start becoming much more active.

I have answered the health questions correctlyand to the best of my knowledge.I understand that all exercise and use of all equipment undertaken and used by myself is at my own riskand I agree to accept such a risk subject to the statutory duty owed to myself by ASK Fitness.

Signature