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I declare that I am over the age of 18 and I agree to the Terms and Conditions. Terms and Conditions.

I agree to the Centre Terms and Conditions. Centre Terms and Conditions.

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Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?

Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?

Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?

Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?

Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?

#	Questions	Answer
1	Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
2	Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
3	Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
4	Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
5	If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
6	Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
7	Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?

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If you have answered "NO" to all of the questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise.

I agree that if any of the information declared (above or herein) changes following the submission of this form, I will inform the centre and present for additional assessment in person by authorised staff before continuing to use the facilities. *

I believe that to the best of my knowledge, all the information I have supplied is correct. *

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