Laburnum Gym Medical Questionnaire
Name:…………………………………….……… Date of Birth:……………………….. Email:……………………………………………. Telephone:………………………..… GP Name:…………………………………………………………………………………... Emergency Contact: ………………………………………………………………….…..
All information given here is confidential and held in accordance with the Data Protection Act (1998)*
Common sense is the best guide when answering these questions but if in doubt, please consult your doctor. Please read the questions carefully and answer each one honestly by ticking yes or no.
1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? Yes o No o
2. Do you feel pain in your chest when you do physical activity? Yes o No o
3. In the past 6 months have you had chest pain when you are not doing physical activity? Yes o No o
4. Do you lose balance because of dizziness or do you ever lose consciousness? Yes o No o
5. Do you have a bone or joint disorder that could be made worse by a change in your physical activity? Yes o No o
6. Is your doctor currently prescribing drugs (i.e water tablets) for your blood pressure or heart condition? Yes o No o
7. Have you ever had high blood pressure? Yes o No o
8. Do you have a respiratory disorder, such as asthma? Yes o No o
9. Are you on any medication? (if yes please state) Yes o No o
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10. Do you know of any reason why you shouldn’t exercise? (if yes please give details) Yes o No o
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11. How did you hear about our gym
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12. What are your aims in joining the gym?
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13. How often would you like to use the gym?
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Please read and sign the following declaration:
I acknowledge the information given above is correct to the best of my knowledge at the time of completion. I undertake to inform you immediately if any of the above changes. Information provided on this form will be stored securely and used in accordance with the Data Protection Act 1998.
I understand to use the fitness facility to exercise only in accordance with the instructions of the fitness staff. I acknowledge that any use of the facilities, equipment and participation in physical activity is entirely at my own risk. In addition I agree not to use the gym equipment without successfully completing the gym induction.
I recognise that when a gym instructor is not present in the gym, there MUST be a minimum requirement of TWO PEOPLE in the gym at any one time.
Signed: ………….………………………………… Date:.……………………………
*By completing this form, you give your consent: For this information to be kept on our secure database and may be used in case of emergency and the development of this service. Age UK West Sussex anonymises this information for statistical purposes. We will not pass your details to third parties without your permission.
Charity Log No:
Version 2 Aug 2016