Health & Safety Questionnaire

Regular physical activity has many health benefits, however, some people should check with their doctor before they start. When planning to undertake physical activity, you should start by answering the questions below. If you are in any doubt, consult with your G.P. before commencing exercise. Please read the questions carefully and answer them honestly by circling YES or NO.
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? YES / NO
2 Do you feel pain in your chest when you do physical activity? YES / NO
3 In the past month, have you had chest pain when you were not doing physical activity? YES / NO
4 Do you lose balance because of dizziness or do you ever lose consciousness? YES / NO
5 Do you have a bone or joint problem that could be made worse by a change in your physical activity level? YES / NO
6 Have you ever had any problems with your back? YES / NO
7 Is your doctor currently prescribing any medication for your blood pressure or a heart condition? YES / NO
8 Is there any family history of heart disease, stroke, raised cholesterol or high blood pressure? YES / NO
9 Do you suffer from diabetes/epilepsy/asthma? YES / NO
10 Are you pregnant, or have you given birth in the last six weeks? YES / NO
11 Do you have, or have you had any illnesses recently? YES / NO
12 Have you recently had surgery? YES / NO
13 Do you know of any other reason why you should not do physical activity? YES / NO
14 What are your aims for exercising?___________________________________________________________
15 Present and past activity levels, how often and what type?________________________________________

If you have answered ‘yes’ to any of the questions above, please can you give brief details: (We may require you to obtain written consent from your G.P. before agreeing to allow you to undertake any physical exercise in the gym) I have read and fully understood the Health & Safety Questionnaire. I confirm that, to the best of my knowledge, the answers are correct and accurate. I know of no reason why I should not participate in an exercise workout. I understand that I would be using the Health & Fitness facilities entirely at my own risk and waive any legal recourse for damages to myself or property arising from my participation. I have understood and answered all of the above questions honestly. I understand that I should not exercise if I feel unwell and that if my health changes I should inform my instructor.