• Exercise & Health Self Assessment

    Exercise & Health Self Assessment

  • Medical Information

  • Do you have a bone, muscle, tendon or joint condition that may affect how you need to exercise?*
  • Do you have any other condition that we should be aware of that may affect how you need to exercise?*
  • Do you have a heart condition?*
  • Are you being treated for a blood pressure condition?*
  • Do you have diabetes?*
  • Do you get asthma?*
  • Do you carry medication?*
  • Do you experience epilepsy?*
  • Do you get dizzy, faint or lose consciousness when under exertion?*

  • Exercise History

  • Are you normally active?*
  • Do you do any other forms of exercise?*
  • Are you new to exercise classes?*

  • 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. 

     

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