Myles Price Fitness Health & Safety Questionnaire

1

Name

2

1. History of heart problems (i.e. chest pains, heart murmur, stroke)

YesNo

3

2. Diabetes (Type 1 or 2)

YesNo

4

3. Asthma, breathing or lung problems

YesNo

5

4. Allergies

YesNo

6

If so what allergies?

7

5. Cancer

YesNo

8

6. Seizures, neurological problems or dizziness

YesNo

9

7. High or low blood pressure

YesNo

10

8. Back Pain

YesNo

11

9. Joint pain or muscle disorder aggravated by exercise

YesNo

12

10. Hernia or any other condition aggravated by exercise

YesNo

13

11. History of high cholesterol

YesNo

14

12. Family history of coronary heart disease

YesNo

15

13. Do you smoke

YesNo

16

If so how much per week?

17

14. Do you consume alcohol

YesNo

18

If so how much per week?

19

16. Do you take supplements of any kind?

YesNo

20

If so specify below

21

17. Are you currently on any medication?

YesNo

22

18. Are you currently pregnant?

YesNo

23

If you proceed with a programme of physical activity and, during that period your health changes so that you subsequently answered YES to any of the above questions please notify us immediately, as you may need to change, or even suspend your physical activity plan.

I accept

I don’t accept

24

I have volunteered to participate in a fitness regimen provided to me by Myles Price Fitness, which may include, but may not be limited to, resistance training and aerobic or cardiovascular exercise. In consideration of the Trainers agreement to instruct and train me, I do here now and forever release and discharge and hereby hold harmless Myles Price Fitness and their respective Trainers, from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in this or any exercise programme including any injuries resulting there from.

I accept

I don’t accept

25

I have been/ I am being informed, understand and am aware that any exercise programme, whether or not requiring the use of exercise equipment, is a potentially hazardous activity. I also have been/ I am being informed of, understand and am aware that any exercise and/or fitness activities involve a risk of injury, as well as abnormal changes in blood pressure, fainting, and a remote risk of heart attack, stroke, other serious disability or death, and that I am voluntarily participating in these activities and using equipment and machinery with full knowledge, understanding and appreciation of the dangers involved. I hereby agree to expressly assume and accept any and all risks of injury, regardless of severity, or death.

I accept

I don’t accept

26

Myles Price Fitness advise that an examination by a physician should be obtained by anyone prior to commencing a fitness and/or exercise programme, or initiating a substantial change in the amount of regular physical activity performed. If I have chosen not to obtain a physician’s consent prior to beginning this fitness programme with Myles Price Fitness, I hereby agree that I am doing so solely at my own risk. In any event, I acknowledge and agree that I assume the risks associated with any and all fitness related activities and / or exercises in which I participate.

I accept

I don’t accept

27

THIS WAIVER AND RELEASE OF LIABILITY INCLUDES, WITHOUT LIMITATION, INJURIES WHICH MAY OCCUR AS A RESULT OF EQUIPMENT BELONGING TO TEAM RYANO KILKENNY/MYLES PRICE FITNESS OR TO MYSELF THAT MAY MALFUNCTION OR BREAK; ANY SLIP, FALL, DROPPING OF EQUIPMENT; AND/OR NEGLIGENT INSTRUCTION OR SUPERVISION.

I accept

I don’t accept

28

I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS FORM IN ITS ENTIRETY AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY. BY ACCEPTING BELOW THIS DOCUMENT I AM WAIVING ANY PERSONAL RIGHT OR ANY RIGHTS MY SUCCESSOR’S MIGHT HAVE TO BRING LEGAL ACTION OR ASSERT A CLAIM AGAINST TEAM RYANO KILKENNY/MYLES PRICE FITNESS FOR YOUR NEGLIGENCE OR THAT OF YOUR TRAINERS.

I accept

I don’t accept