Name of Participant over 18 (or name of parent/guardian if completing for under 18) *

First Name

Last Name

Name of Participant if under 18

First Name

Last Name

Have you ever had a heart attack, coronary revascularisation surgery, or a stroke? *

Yes

No

Has your doctor ever told you that you have heart trouble or vascular disease? *

Yes

No

Has your doctor ever told you that you have a heart murmur? *

Yes

No

Do you ever suffer from pains in your chest, especially during exercise? *

Yes

No

Do you ever get pains in your calves, buttocks, or back of your legs during exercise that is not due to soreness or stiffness? *

Yes

No

Do you ever feel faint or have spells of severe dizziness, especially during exercise? *

Yes

No

Do you experience swelling or accumulation of fluid around the ankles? *

Yes

No

Do you ever feel your heart is suddenly beating faster, racing or skipping beats, either at rest or during exercise? *

Yes

No

Do you have chronic obstructive pulmonary disease, interstitial lung disease, or cystic fibrosis? *

Yes

No

Have you ever had an attack of shortness of breath that developed when you were not doing anything strenuous at any time in the last 12 months? *

Yes

No

Have you ever had shortness of breath that developed after you stopped exercising at any time in the last 12 months? *

Yes

No

Are you pregnant? *

Yes

No

Do you have diabetes [IDDM or NIDDM]? If so, do you have trouble controlling your diabetes? *

Yes

No

Do you have any ulcerated wounds or cuts on your feet that do not seem to heal? *

Yes

No

Do you have any liver, kidney, or thyroid disorders? *

Yes

No

Do you experience unusual fatigue or shortness of breath when doing everyday activities? *

Yes

No

Is there any other physical reason or medical condition or are you taking any medication(s) which could prevent you from undertaking an exercise program? *

Yes

No

Affirmation *

Being aware of my own health and physical condition, and having knowledge that my participation in any exercise program may be injurious to my health, am voluntarily participating in physical activity.

Having such knowledge, I hereby acknowledge this release, any representatives, agents and successors from liability for accidental injury or illness which I may occur as a result of participating in the said physical activity.

I hereby assume all risks connected therewith and consent to participate in said program.

I agree to disclose any physical limitation, disabilities, ailments or impairments which may affect my ability to participate in said fitness program.

To be completed by Parent/Guardian of under 18 participant

I have completed the above on behalf of the participant who I am Parent/Guardian to and confirm the information is correct and has been completed by myself on their behalf

I confirm I am the responsible party for the under 18 participant and give permission for them to train at Fitquest360 with a Personal Trainer.