60s + Club Health Screening Form
Physical activity has positive effects on the body e.g. improving body shape, making the heart stronger, relieving stress etc. If you haven’t participated in exercise for many years and have high cholesterol, sudden exercise could be fatal. So before undergoing regular physical activity please fill out this health screening form so I can see your capabilities and limitations.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Has your doctor diagnosed a bone or joint problem, such as arthritis, that has been aggravated or made worse with exercise?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Do you have low blood pressure?
*
Yes
No
Do you have Diabetes Mellitus or any other metabolic condition?
*
Yes
No
Has your doctor ever said that you have raised cholesterol (serum level 6.2 mmol/L)?
*
Yes
No
Have you ever been diagnosed with a heart condition and advised that you should only do physical activity recommended by your doctor?
*
Yes
No
Have you ever felt chest pain during physical activity?
*
Yes
No
Is your doctor prescribing you drugs or medication?
*
Yes
No
Have you ever suffered from shortness of breath at rest or with mild exertion?
*
Yes
No
Is there any history of Coronary Heart Disease in your family?
*
Yes
No
Do you feel faint, have spells of severe dizziness or have lost consciousness?
*
Yes
No
Do you currently smoke?
*
Yes
No
Do you know of any other reason why you should not participate in an exercise class?
*
Yes
No
If you answered YES to any of the questions above or know of any reason not to participate in an exercise class, please leave details below:
If you answered yes to any of the above, we recommend that you seek medical advice as to your suitability to participate in classes. By signing this health screening form you confirm that that you have received medical advice and have been cleared to participate in physical activity. If you develop any new medical condition you are advised to seek further medical advice as to your continued suitability to participate in physical activity.If at any time you receive medical advice that prohibits your participation in physical activity you agree to advise Ty Paul of this, and withdraw from classes. Assumption of Risk - I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance exercise and stretching. I realise that my participation in these activities involves a risk of injury and even the possibility of death. I confirm that I am voluntarily engaging in these activities and do so entirely at my own risk.
*
Clear
Submit
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