Health Questions – MSE Outdoor Fitness

Prefix

First Name

Last Name

Street Address *

City

County

Post Code

Phone *

Mobile

Email Address *

Date of Birth *

Day

Month

Year

Age

How did you find out about MSE?

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First Name

Last Name

Relationship

Phone

Other Info

Has a doctor ever said you have a heart condition & that you should only do physical activity which they have recommended to you? *

Do you feel pain in your chest during physical activity? *

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

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

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

Have you ever been told by your doctor that you have high blood pressure? *

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

Do you suffer from epilepsy? *

So you have diabetes mellitus? *

Do you suffer from an allergy? *

You said yes to Allergies so what Allergies do you have & what medication do you take?

Do you suffer from asthma or shortness of breath at rest or with mild exertion? *

Do you suffer from unusual fatigue with usual activities? *

Do you suffer regulary get a sharp pain in your lower leg when walking uphill upstairs, whuch disapperas within 1-2 minutes of stopping? *

Are you, or is there a possibility that you are pregnant? *

Do you know of any other reason why you should not do physical activity? *

How would you describe your current fitness levels? *

WARNING

If you have answered YES to one, or more, of the questions previously, we would advise you to speak to your GP before participating in MSE Outdoor Fitness Classes. If in any doubt, please ask your doctor's advice about your suitability to participate in progressive and unrestricted physical activity.

Declaration

In consideration of being allowed to participate in the activities & programmes of MSE Outdoor Fitness, I acknowledge that:

1. I am aware of, and understand the potential risks and dangers associated with physical activities, including the use of the equipment and I am voluntarily participating in these activities with knowledge of the risks and dangers involved.

2. I understand that exercise and physical activities in the outdoors involve the risk of injury or even death and that I am voluntarily participating in these activities and using equipment and facilities with the knowledge of the dangers involved. I hereby assume all and any risks of injury or death.

3. I know of no reason why I should not participate in any of the programmes or activities of MSE Outdoor Fitness. I hereby declare myself free of any condition, disease, infirmity, or illness that may affect my participation. I agree to inform a member of staff, and where appropriate, provide written consent from my doctor should such a condition or complaint arise before continuing with any activity.

4. I agree to abide by all oral notices regarding safety while at an MSE Outdoor Fitness class. I am aware I have the opportunity to ask questions about the activities, the general use of the equipment, and any other related issues in class. If I choose not to take advice or to disregard any advice given, I do so voluntarily and accept liability for all resulting injuries or damage.

5. I do hereby waive, release and discharge MSE Outdoor Fitness from any responsibility or liability for injuries or damages sustained from my participation in any activities or my use of equipment or facilities in the above-mentioned activities.

6. This questionnaire has been completed accurately to the best of my knowledge and belief

Date *

E-Signature

Please type your name in the signature box below and select the date.

By doing so you agree that this will be defined as an electronic signature and should be given the same legal force and effect as a handwritten signature and that you wish to authenticate the declaration with this electronic signature.