Pre-Exercise Questionnaire

Name*

DOB*

Emergency Contact*

Emergency Contact Phone*

Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?*

Yes
No

Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?*

Yes
No

Do you ever feel faint or have spells of dizziness during physical activity /exercise that cause you to lose balance?*

Yes
No

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*

Yes
No

If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last three months?*

Yes
No

Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?*

Yes
No

Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?*

Yes
No

If you answered Yes to any of the 7 questions above written medical clearance is required prior to gym use. If you answered No to all of the 7 questions above, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise.

If you are currently taking medication please name the condition it is for:

I hereby represent to NORTHS Fitness Centre, its employees and affiliates that I am physically capable of, and there is no medical reason to prevent me from, proceeding with the use of the gymnasium facilities without endangering my health. I understand that NORTHS Fitness Centre is not able to provide me with medical advice regarding my medical fitness and that the information provided on this form is used as a guideline to the limitations of my ability to exercise. I represent and warrant that all information on this form is correct and that any alteration to my health must be reported to NORTHS Fitness Centre immediately and may require written medical clearance prior to continuing my exercise routine. I acknowledge that whilst within the gym facilities my person, guests, property and guest’s property are at my own risk. I acknowledge I will not hold NORTHS Fitness Centre, or its employees and affiliates, responsible for, and the club hereby excludes to the extent permitted by law, all liability for any personal injury or damage (whether direct, indirect, special or inconsequential) suffered by me or my guest, or loss of property suffered by me or my guest, while I am in the gymnasium facility or arising in any way out of the use of the facilities and equipment provided by NORTHS Fitness Centre, regardless of how the injury, damage or loss is caused. By signing this form I confirm I have been given the NORTHS Fitness Centre membership Terms and Conditions document and have had the opportunity to read and understand the conditions of my membership and any associated billing arrangements.

Terms and Conditions*

I agree to the terms above

Pre-Exercise Questionnaire

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