Health Screen | Lakeside Gym South Cerney

GYM HEALTH SCREENING

All information is private and confidential.

For you own safety, if you answer "Yes" to any of the following questions, we may not be able to allow you access to the gym unless you can provide us with a waiver from your Doctor indicating that it is safe for you to do so.

First Name

Email Address

Last Name

Date of Birth

Do you, or have you ever suffered from any of the following:

Diabetes
High or Low Blood Pressure
Physical Handicaps
Asthma
Respiratory Problems
Epilepsy
Conditions associated with Heart Disease
Arthritis or stiff joints
Back Pain
Hip Pain
Other joint injury
Blackouts
Are you taking any medication which might affect you during exercise?
Do you know of any illness or injury not in the above list that may be aggravated by regular exercise?

Yes

Doctors Waiver

To the best of my knowledge I have completed this health assessment form correctly and have stated any medical conditions which may restrict my ability to participate in the use of the gym equipment. It is my responsibility to inform you of any medical changes that may arise.

I understand that you offer a free gym introduction/assessment and that it is my responsibility to make an appointment with the gym instructor.

I fully understand the importance of the above statement and I take full responsibility for my actions and my wellbeing.

Today's Date

Thanks for submitting.

OPEN

EVERY DAY

GYM HEALTH SCREENING

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