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PRE-EXERCISE HEALTH SCREENING FORM |
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These questions are designed to assess your suitability for exercise. Please provide the information as accurately as possible, reading the questions carefully. Your name : ......................................................................………………………………… Address : ........................................................................................................................….. .........................................................................……………. Postcode:…………………… Home tel no: ………………………………. Date of birth: ………/………/……….. Email address: ………………………………………………………………………………………………… GP name & surgery ............................................................................................…………... GP Phone no ………………… & an emergency contact no: ……………………………. Do you suffer, or have you ever suffered from any of the following?: tick Yes / No and Where appropriate, please give as much detail as possible in space provided -
Fitness
Declaration I
understand that whilst every care will be taken to give safe
instruction, I accept full responsibility and consider myself fit to
exercise. I have answered
all the questions correctly and all medical and health considerations
are noted above. I will
keep the instructor updated on above Signed
.......................................................................……………
Date : ........................................
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