Fitness Health Form
(Under 18)
Name:
*
First Name
Last Name
Date of Birth:
*
/
Day
/
Month
Year
Age:
*
Full Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
Health Check:
For most people physical activity should not pose any problem or hazard. This health questionnaire has been designed to identify the small number for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them
Common sense is your best guide in answering these few questions. Please read them carefully and check the question which applies to you. Details will be noted overleaf.
Have you had surgery in the past 12 months?
Chest Pains?
Long Covid
Severe headaches or Dizziness?
Back Pain?
High/Low Blood Pressure?
Asthma?
Epilepsy/Diabetes
Are you pregnant or have you recently given birth?
Muscle type problems (Bone/Joint)?
Current injuries?
Heart Problems?
Are you on any medication?
Is there any good reason not mentioned here why you should not follow a graduated exercise programme?
What exercise are you currently undertaking?
*
What are your aims/goals?
*
Declaration
I confirm that the information above is correct. I agree to inform an instructor in the event that the answer to any of the above questions should change. I also agree to use only the equipment which has been demonstrated to me by an instructor and will seek advice about the use of any equipment where I am unclear about its safe use. I understand that the YMCA and its employees will not accept liability for injury caused to me where such injury is the result of my failure to use the equipment properly: my failure to seek advice about the proper use of the equipment: or my failure to inform YMCA of my actual health status: or otherwise as a result of my or a third party’s negligence.
Customer
Full Name:
*
Date:
*
/
Day
/
Month
Year
Signature:
*
Clear
Parent/Guardian
If you are under 18 years of age we require permission from a parent/guardian for you to use our facilities.
Full Name:
*
Date:
*
/
Day
/
Month
Year
Signature:
*
Clear
Emergency Contact Information
Name:
*
Phone Number:
*
-
Area Code
Phone Number
Submit
Should be Empty: