Contact Information
Emergency Contact and Physical Activity Readiness Questionnaire - v.300517
We use your own contact details you provide so we can keep you up to date with HGG activities. The other information you give will be used only in case of an emergency (e.g.medical). This information will be stored electronically, protected by passwords. Horsham Green Gym respects your privacy and will not disclose your personal details to a third party except in an emergency.
Your NAME *
Your answer
Your ADDRESS *
Your answer
Your POSTCODE *
Your answer
Your EMAIL address (insert 'none' if applicable) *
Your answer
Your HOME phone number *
Your answer
Your MOBILE phone number (insert 'none' if applicable) *
Your answer
Show your DATE OF BIRTH in the form dd/mm/yyyy *
Your answer
>>EMERGENCY<< CONTACT (name, address) *
Your answer
>>EMERGENCY<< PHONE NUMBER -- LANDLINE *
Your answer
>>EMERGENCY<< PHONE NUMBER -- MOBILE *
Your answer
Is there any work you may find difficult for health reasons? If 'yes' give brief reason. *
Your answer
Are you taking any medication that a First Aider or Doctor would need to be aware of? If 'yes', please list. *
Your answer
Is there any information we may need to ensure your safety (e.g. colour blindness, hearing impairment, learning disability)? If 'yes' give more (brief) information. *
Your answer
For most people, physical activity should not pose any problem or hazard but this questionnaire has been designed to identify the small number of people for whom it would be wise to have medical advice before starting. Please answer the eight questions below.
Also, use the space after question 8 to tell us of any other conditions you feel we should be aware of. If none, please reply 'none'.
1. Has your doctor ever said that you have a heart condition? *
2. Do you feel pain in the chest when you do physical activity? *
3. In the past month have you had a pain in your chest when you were not doing physical activity? *
4. Do you lose your balance because of dizziness or do you ever lose consciousness? *
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
6. Do you have diabetes? *
7. Do you have asthma? *
8. Do you have any allergies? *
If you answered 'YES' to any of the above questions, please give a little more information. If you answered 'NO' to all the questions and do not need to mention any other conditions, enter 'none' *
Your answer
By ticking the 'agree' box (or, your signature below, in the case of the form being completed on paper), you agree to informing Horsham Green Gym (HGG) in writing of any medical condition which might put you at risk when taking part in our activities, HGG storing the information you provide and to follow the Leader's instructions. Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (only when being completed on paper) *
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