Thank You

Please fill the Medical Questionnaire and Informed Consent form

STRICTLY PRIVATE AND CONFIDENTIAL

Client No. Copied Yes No

Medical Questionnaire and Informed Consent

CUSTOMER DETAILS

Applicant 1
Title: Mr/Mrs/Ms/other Contact Name
First Name: Surname:
Date of Birth:    
Address
  Postcode
Telephone: Mobile:
Email: Type of membership required:
Emergency Contact Details:    

DECLARATION

I/we hereby agree to abide by the terms and conditions of Dan Bennett MBF Personal Training, a copy of which I/we have read and retained.
Signed: Date:

SECTION 1 Part A

Common sense is your best guide to answering these questions. Please read them carefully and tick the correct answer.
Yes No  
1. Has your doctor ever said you have heart trouble?
2. Do you, or have you ever had, unexplained pains in your chest?
3. Are you currently or have you ever received treatment for epilepsy?
4. Has your doctor ever told you that you have a bone or joint problem such as arthritis that may be made worse by exercise?
5. Have you ever been diagnosed as diabetic?
6. Has a doctor ever said your blood pressure was too high? (Except during pregnancy)
7. Are you pregnant?
8. Are you taking any medication prescribed by your doctor for your blood pressure, a heart condition or other serious illness?
9. Are you over 55 and not accustomed to exercise?
10. Is there a good reason not mentioned here, why you should not follow an activity programme even if you wanted to?