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Ready to exercise?
Date of Birth
Experience any of the following (past or present)? Tick all that apply.
Heart condition/or diease (for yourself or within your family)
Chest pains/shortness of breath
Asthma, chronic bronchitis or other chest ailments
Dizziness or feeling faint
High/low blood pressure or high cholesterol
Back pain or other bone/joint problem
Severe headaches or migraines
Recovering from recent illness/injury/medical procedure
Currently pregnant or given birth in last 6 months
Issues with pelvic floor health
Presently taking medication?
Any other medical condition I should be aware of?
Any injury, aches, pains or problem area's I need to know about?
If you ticked any boxes above please give details. You are advised to see your GP before engaging in any physical activity
I declare that the information I have provided is accurate & complete
Signature (print name)
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