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Health Screening Form
The questions below are about your general health and well-being.
First and Last Name *
Your answer
Date Of Birth *
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Address *
Your answer
Post Code *
Your answer
Email addess *
Your answer
Home Telephone Number
Your answer
Mobile Number *
Your answer
Person to contact in an Emergency *
Your answer
Their contact number *
Your answer
Have you ever suffered from any of the following medical conditions?
If you have answered yes to any of above medical conditions, please give details.
Your answer
Are you, or is there any possibility that you are pregnant? *
Have you had a baby in the last six months? *
Do you smoke? *
If YES, how may per day
Your answer
Has your doctor ever advised you against any form of exercise? *
If YES, please explain
Your answer
Are you presently taking any medication on a regular basis? *
If YES, please list names and dosages of each
Your answer
Are you currently on a specific diet? *
If YES, please give details
Your answer
Are you aware of any injury, past or present, which may be aggravated by any form of exercise? *
Required
If YES, please explain
Your answer
Do you know of any other reason why you should not do physical activity? *
Your answer
To the best of my knowledge , the above information is accurate and complete. I wish to take part voluntarily in exercise prescribed by staff at SP Fitness Solutions in order to attempt to improve my physical fitness. All programmes will be designed to place a gradually increasing workload on the body in order to improve fitness. The rate of progression will be regulated on an ongoing basis. The reaction of the cardio-respiratory system to such activities cannot be predicted with complete accuracy. I realise that there is a risk of certain changes accruing during or following the exercise and understand that these changes may include some abnormalities of blood pressure or heart rate. I understand that I am responsible for monitoring my own condition throughout the exercise programme and, should any unusual symptoms occur, I will stop my participation and inform the instructor immediately. In the event that medical clearance must be obtained prior to my participation in the exercise programme, I agree to consult with my doctor prior to the commencement of any exercise programme. Also in consideration for being allowed to participate in the exercise programme, I agree to assume the risk of such exercise and further agree to hold the trainer or SP Fitness Solutions blameless or not responsible. *
Required
Date *
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Would you like to be contacted by email about our products and promotions? *
I give permission to SP Fitness Solutions for photographs/video/sound recordings of me to be captured and used in printed and electronic media, including the internet for promotional purposes.I understand that some images or recording may be selected for permanent preservation in the business archive as a record of fitness and may be used for research, publication, broadcasting, public performance, displays and exhibitions. *
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