WABC - Membership Form 2020/2021

Name*

First NameLast Name

Emai Address*

Contact Number*

Physical Activity Readiness Questionnaire

1. Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse with exercise?*

YESNO

2. Do you have high blood pressure?*

YESNO

3. Do you have a low blood pressure?*

YESNO

4. Do you have Diabetes Mellitus or any other metabolic disease ?*

YESNO

5. Has your doctor ever said you have raised cholesterol (serum level above 6.2mmol/L)?*

YESNO

6. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?*

NOYES

7. Have you ever felt pain in your chest when you do physical exercise?*

YESNO

8. Is your doctor currently prescribing you medication?*

YESNO

9. Have you ever suffered from unusual shortness of breath at rest or with mild exertion?*

YESNO

10. Is there any history of Coronary Heart Disease in your family?*

YESNO

11. Do you often feel faint, have spells of severe dizziness or have lost consciousness?*

YESNO

12. Do you currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women)?*

YESNO

13. Do you currently smoke?*

YESNO

14. Do you currently exercise less than 3 times a week?*

YESNO

15. Are you, or there any possibility that you might be pregnant?*

YESNO

16. Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in your physical activity?*

YESNO

17. Do you know of any reason why you should not take part in physical activity?*

YESNO

If YES, please comment:

Member Declaration

If you answered YES to one or more questions:

You should consult your doctor or a qualified health professional before becoming physically active at this time and in your current state of health.

If you answered NO to all questions:

It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.

Please speak to the instructor before participating if this is your first time attending this class.

Declaration:

I confirm that I have read, understood and answered the questions above honestly. I understand that participation in physical activity may include aerobic exercise, resistance exercise and stretching, and that this involves a risk of injury. I confirm that I am voluntarily engaging in physical activity at an appropriate level for my current health and fitness.

Signature*

First NameLast Name

Having answered YES to to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise.

Signature*

First NameLast Name

Member Declaration:

I agree to abide by the Rules and OPH's Values

All participants under the age of 18 years must obtain parental/adult consent prior to participation.

DECLARATION - Member*

DECLARATION - Parent/Guardian (for members under 18 years of age)

DATE:

Date