Exercise and Health Self Assessment

Name

First NameLast Name

Date of Birth

Do you have a bone, muscle, tendon or joint condition that may affect how you need to exercise?*

YesNo

If yes, please provide details

Do you have any other condition that we should be aware of that may affect how you need to exercise?*

YesNo

If yes, please provide details

Do you have a heart condition?*

YesNo

Are you being treated for a blood pressure condition?*

YesNo

Do you have diabetes?*

YesNo

Do you get asthma?*

YesNo

Do you carry medication?*

YesNo

Do you experience epilepsy?*

YesNo

Do you get dizzy, faint or lose consciousness when under exertion?*

YesNo

Are you normally active?*

YesNo

Do you do any other forms of exercise?*

YesNo

If so what do you do?

Are you new to exercise classes?*

YesNo

I believe that, to the best of my knowledge, all the information I have supplied is correct.

I agree that it is my responsibility to alert my instructor in any changes in my health status.

In signing this document, I am agreeing to allow the information to be reviewed and used for consultancy as required with relevant employees of Yarrunga Community Centre only.

I agree to assume full responsibility for any risks, injuries or damage, known or unknown which I might incur as a result of participating in the program.

I knowingly, voluntarily and expressly waive any claim I may have against Yarrunga Community Centre for injury or damages that I may sustain as a result in participating in the program.

Applicant's Signature*

Date

Exercise & Health Self Assessment

Medical Information

Exercise History