GYM & FITNESS LIABILITY WAIVER Name * First Name Last Name Email * Date of Birth * MM DD YYYY Has a doctor ever said that you have bone or joint problems such as arthritis, that has been aggravated by exercise or made worse with exercise? * YES No Do you have Diabetes Mellitus or any other metabolic disease? * YES NO Yes Has your doctor ever said that you have raised cholestrol (above 6.2mmol/l)? * YES NO Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by your doctor? * YES NO Have you ever felt pain in your chest when you do physical activity? * YES NO Is your doctor currently prescribing you any drugs or medication? * YES NO Have you ever suffered from shortness of breath at rest or with mild exertion? * YES NO Is there a history of heart problems in your family? * YES NO Do you often feel faint, have spells or severe dizziness or have lost consciousness? * YES NO Do you currently drink more than the average amount of alcohol each week (21 units for men and 14 units for women)? * YES NO Do you currently smoke? * YES NO Do you NOT currently exercise on a regular basis (at least 3 times per week)? * YES NO Are you, or is there a possibility that you might be pregnant? * YES NO Do you know of any other reason why you should not participate in a programme of physical activity? * YES NO If you answered YES to any of the above questions, please provide us more information here: Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name & Number * I declare that the information provide is accurate & complete. * YES I hereby acknowledge this release from liability for accidental injury or illness which I may incur as a result of participating in any physical activity. I hereby assume all risks connect therewith and consent to participate in this program. I agree to disclose my physical limitations, disabilities, ailments or impairments which may affect my ability to participate in this program. * AGREE Initial to Sign* * Thank you!
