Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Gender

Male

Female

1. Have you ever suffered from heart trouble? *

Yes

No

2. Are you presently taking any form of medication? *

Yes

No

3. Do you suffer from chest pains? *

Yes

No

5. Have you ever had either high or low blood pressure, and/or high cholesterol level? *

If YES please indicate which:

Yes

No

6. Have you ever had asthma, chronic bronchitis or any other chest ailments? *

If YES please indicate which:

Yes

No

7. Do you suffer from back pain or any orthopaedic problem? *

If YES please indicate which:

Yes

No

8. Do you suffer from severe headaches or migraines? *

Yes

No

9. Are you recuperating from a recent illness/operation or injury? *

If YES please expand:

Yes

No

10. Have you any medical condition that we should be aware of? *

Yes

No

11. Are you pregnant? If yes, how many months? *

Yes

No

12. Is there any history of heart disease in your immediate family (under the age of 55)? *

Yes

No

Date of Birth *

MM

DD

YYYY

PLEASE NOTE: If you answered YES to any of questions 1-12, you are advised to seek medical advice/approval before commencing an exercise induction or exercise programme or consult further with your instructor. I have been informed both verbally and in writing that if I answer YES to any of questions 1-12 of this questionnaire, I should seek medical advice/approval before commencing an exercise programme and/or induction. If I wish to continue without such advice I do so entirely at my own risk. I confirm that I have read, fully understood and answered the above questions honestly. I understand that the Centre and any of its employees cannot be held responsible for any injuries or ill health arising from my participation in the exercise programme. *

By ticking the box below you are agreeing to the terms above

I agree to the terms above