Coral Leisure Internal Audit Document

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Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.All customers wishing to attend the Gym or Pool Spa area must be at least 16 years of age. Photographic ID may be required to confirm date of birth.
Month
Day
Year
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Phone Number* This field is required.
Area Code
Phone Number
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I confirm that I do not have any of the following health issues and am fit for Gym, Fitness Classes, Pool, Sauna, Steamroom and Jacuzzi use.

Health Screening

If you answer YES to any of these questions then you must confirm that you are under the care of a doctor and that your health issue is currently under control or get a doctor’s note before using these facilities.

·      Do you have a heart condition?

·      Do you suffer from chest pains at rest or upon exertion?

·      Do you experience dizzy spells?

·      Do you have high / low blood pressure?

·      Have you any major injuries? - Back, Knees, Hips, Ankles, etc.

·      Have you any major medical conditions such as;

-Epilepsy

-Asthma

-Diabetes

·      Are you currently or have recently been pregnant?

·      Have you had surgery in the last 12 months?

· Is your G.P. aware of your intent to exercise?

·      Have you any other health issues that may affect you when exercising?
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I confirm that I do not have any of the health issues above and am fit for Classes, Pool, Sauna, Steamroom and Jacuzzi use. I also confirm I am a regular Gym User and I am familiar with the safe use of all equipment am aware that I can request an induction on this equipment at any time.* This field is required.If the answer to this is NO, a Doctors Note may be needed before use of our facility.
YESNO
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If you have answered NO to the previous question, please add any relevant details below:
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Large
Normal
Small
Ok
Ok
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I confirm that if I am 15 years of age or younger and I will not use any resistance machines or weights in the gym or use the Pool Spas areas (Sauna, Steamroom and Jacuzzi).* This field is required.PLEASE NOTE: You may be asked to produce photographic ID to verify age.
YESNO
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Signature* This field is required.I declare that I have answered the Customer Health Screening Questionnaire to the best of my knowledge. I am also aware that physical activity may be hazardous and that there may be risk involved. I acknowledge that I participate in the use of the facilities at my own risk and take full responsibility for my actions.
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