Medical Assessment Form

Please answer the following medical questions truthfully. This form needs to be renewed every 12 months.

First name

Last name

Email address

Date of birth

Day

Month

Year

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

Yes

No

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

Yes

No

In the past month, have you had chest pain when you were not doing physical activity?

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness?

Yes

No

Do you have a bone or joint problem (e.g., back, knee or hip) that could be made worse by a change in your physical activity?

Yes

No

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

Yes

No

Do you know of any other reason why you should not participate in physical activity?

Yes

No

Important Notice:

If you answered YES to one or more questions: You should consult your doctor to gain consent before participating in physical activity.
If you answered NO to all questions: It is considered reasonably safe for you to participate in regular physical activity.

Important Notes:

Should your condition change from a YES to a NO on any question above then this form becomes invalid and should be completed again after consultation with your GP.
You should complete this form every 12 months, depending on renewals.
You should speak to your doctor if there are any changes to your health which would result in answering YES to any of the above questions.
If you are pregnant you should talk to your doctor for approval before becoming more active.

I understand that I am voluntarily engaging in a level of exercise appropriate for my ability and that my participation involves a risk of injury.

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Please sign to confirm all information provided is accurate and true.