Health Screening Form - Mitchelstown Leisure Centre

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certify that I understand the foregoing questions and my answers are true and complete. I also understand that if this information changes in any way in the future, it is my responsibility to notify my trainer, and that I assume the risk for any changes in my medical condition that might affect my ability to exercise. Before beginning a new fitness program or other significant change in your physical activity levels, you are advised to consult with your physician or primary health care provider. Only a physician or qualified health care provider is able to diagnose and prescribe treatment for specific health conditions. I hereby assume full responsibility for any and all injuries, losses and damages that I incur while attending, exercising or participating in Mitchelstown Leisure Centre Gym/Classes. I hereby waive all claims against Mitchelstown Leisure Centre Gym, its instructors, or partners of individually or otherwise, for any and all injuries, claims or damages that I might incur. I acknowledge that I have read the foregoing statements and fully understand the content thereof, and that if I choose not to consult with my physician or primary health care provider, I do so at my own risk.

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Parent or legal guardian (if participant is under age eighteen)

1. Are you accustomed to regular exercise? i.e. three times a week,

Physical activity should not pose any problem or hazard to the majority of people. The following questions are designed to identify the small number of adults for whom physical activity might be inappropriate or those who should seek medical advice prior to initiating a fitness program or other change in their physical activity levels.

2. Have you ever been diagnosed diabetes, asthma or epilepsy?