Pre-Exercise Questionnaire

  • DD slash MM slash YYYY
  • 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.
  • 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.