Health Questionnaire

To register to our gym please fill out the following medical form

Full Name

Course Title/Department

Date of Birth

Student/Staff Number

Please answer by ticking the relevant boxes:

Do you feel any pains in the chest while exercising?

Have you felt any chest pains in the last 6 months?

Have you or do you suffer with a heart disorder?

Do you suffer with high blood pressure?

Are you diagnosed as diabetic?

Do you suffer with epilepsy?

Do you suffer with asthma?

Do you suffer with dizziness or loss of balance?

Have you had any serious illness/operation in the last 12 months?

Do you have any bone or joint problems?

Are you pregnant?

Have you given birth in the last 6 months?

Are you taking any prescribed medication?

Do you smoke?

None of the above.

If you have answered yes to any of the above, please provide relevant details here:

Are you aware of any other reason why you should not exercise?

I declare that the info I’ve provided is accurate & complete

Initials

Today's Date

Thanks for submitting!

Sport Grounds

Foxburrows Lane

Chelmsford

Essex

CM1 3SS

Writtle University College

Sport Centre

Lordship Road

Chelmsford

Essex

CM1 3RR

Telephone: 01245 424200