Please take a few minutes to answer the following questions. All information supplied on this form will be treated as confidential and will not be released without your written consent.
If you have any of the issues listed above, please visit your doctor for clearance before starting any new exercise program. If you have already cleared the above conditions with your doctor, please give further details of your condition(s) below:
Have you ever had or do you currently have any of the following:
ArthritisAsthmaCrampsAre you dieting or fastingDo you smoke
Any pain or major injuries in the following areas:
NeckKneesShouldersBackAnklesAny Muscular Pain
Are there any other conditions which may be reason to modify your exercise program?
If Yes, please specify:
What exercise have you been doing recently?
If taking medication, please list:
Which supplements are you currently taking?
PLEASE READ THE FOLLOWING EXERCISE ADVICE CAREFULLY.
Ask any staff member to guide you into the most suitable class or program. Work at a low level on your first visit and concentrate on learning to do the exercise properly. On each visit, work a little harder but limit yourself to a pace where you can still talk comfortably. Should you suffer any illness, injury or condition in the future, complete this form again. It is recommended by the Australian College of Sport Medicine that all males over 35 and females over 45 should have a medical assessment including an exercise (e.g. cholesterol and lipid count).
STATEMENT: I recognise that the instructor is not able to provide me with medical advice with regard to my medical fitness and that this information is used as a guideline to the limitations of my ability to exercise. I have answered the questions to the best of my ability and understand the advice above
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