Health Screen Questionnaire

Please read the following carefully and answer each one honetly. All information will be treated as confidential. Common sense is your best guide when answering these few questions. Please read them carefully and indicate which YES/NO response is most suitable to you.

Has your doctor ever said that you have a heart condition?*

Yes
No
Third Choice

If yes please provide details

Have you recently had chest pains brought on by exercise?*

Yes
No
Third Choice

If yes please provide details

Do you often feel faint or have spells of severe dizziness?*

Yes
No
Third Choice

If yes please provide details

Are you currently receiving treatment/medication from your Doctor for high blood pressure?*

Yes
No
Third Choice

If yes please provide details

Do you have bone or joint problems that could be aggravated by exercise?*

Yes
No
Third Choice

If yes please provide details

Are you short of breath after extremely mild exertion?

Yes
No
Third Choice

If yes please provide details

Are you pregnant or have you been pregnant in the last six months?*

Yes
No
Third Choice

If yes please provide details

Are you diabetic Type 1 or Type 2?*

Yes
No
Third Choice

If yes please provide details

Have you undergone recent surgery?*

Yes
No
Third Choice

Do you feel there is any reason why you should not participate in an activity program?*

Yes
No
Third Choice

If yes please provide details

If you answered YES to one or more questions it is important to establish exercise implications, and we strongly advise that you consult with your Doctor before beginning any exercise program.

I do confirm that the above answers are correct, at this precise moment, to the best of my knowledge and belief. I will ensure that I inform staff at once if any of the above information changes. I know of no reason why I should not start an exercise program. I agree that any health and fitness induction session I may participate in is in no way a substitute for a full medical examination. I agree that I will not use any piece of equipment without receiving full instructions beforehand in its use from a member of staff. I agree that in signing this document I also sign to say I understand that I shall take part in any recommended program entirely at my own risk and waive any legal recourse against the Council for any personal injury, loss or damage sustained by me or any other person arising from my participation save where such personal injury results from negligence of the Council, its servants or agents or others who have supplied services or equipment to it.

Medical considerations