Online Par Q

To register to our gym please fill out the following medical form

First Name

Email Address

Last Name

Date of Birth

Phone

Read the following questions and select the tick box for any that may apply, leave blank if not applicable.

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

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Do you know of any other reason why you should not do physical activity?

I declare that the info I’ve provided is accurate & complete

Initials

Today's Date

Thanks for submitting!