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Screening Questionnaire

Email *

Name *

Date of Birth *

YYYY

Gender *

Male

Female

Prefer not to say

Height (cm) *

Weight (kg) *

Physical Activity Readiness Questionnaire

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor *

Yes

Do you feel pain in your chest when you do physical activity? *

Yes

In the past month have you experienced any unexplained chest pain? *

Yes

Do you lose your balance due to dizziness or do you ever lose unconsciousness *

Yes

Do you have a bone or joint problem that could be made worse by a change in physical activity? *

Yes

Is your doctor currently prescribing medication for your blood pressure or a heart condition? *

Yes

Do you suffer from asthma? *

Yes

Do you know of any other reason why you should not do physical activity or have any condition that may be made worse by physical activity? *

Yes

Assumption of Risk and Release of Liability: Participating in any physical fitness activity, I recognise and understand that the services offered is not without varying degrees of risk which may include, but are not limited to financial loss, injury or even death, due to negligence, improper use or failure of equipment, medical condition, whether known or unknown to me. I hereby certify that I know of no medical problems that could increase my risk of illness and injury as a result of participation. *

I hereby willingly assume full responsibility for any and all risks and waive any responsibility and liability connected to my participation

I disagree

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