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Settings
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Health Inventory (confidential)
Full Name *
Lot Number (if known) or Street Address *
Email *
Phone Number *
Date of Birth *
DD/MM/YYYY
Sex
Male
Female
Occupation *
Health History Questionnaire
Have you ever had, or being treated for *
(tick all that apply)
Difficulty Breathing
Glandular Fever
High Blood Pressure
High Cholesterol
Rheumatic Fever
Any Heart/Stroke Conditions
Blood Clots in Legs
Varicose Veins
Epilepsy
Pneumonia
Stomach Ulcer
Diabetes
Hernia
Asthma
None of the above
Additional Information
Are you pregnant or attempting to get pregnant?
Yes
No
Have you given birth to a child within the last six months?
Yes
No
Do you suffer pains in your chest?
Yes
No
Do you often feel faint or have faint spells of severe dizziness?
Yes
No
Has anyone in your family ever suffered from Coronary Heart Disease and if so, was it before the age of 65?
Yes
No
Has your doctor ever told you that you have a bone or joint problem such as Arthritis that has been aggravated by exercise or might be made worse with exercise?
Yes
No
Is there a good physical reason not mentioned here why you should not follow an activity program?
Yes
No
Do you take any prescribed medication?
Yes
No
Have you had any major surgery or injuries in the last three years?
Yes
No
Are you over 45 and unaccustomed to vigorous exercise?
Yes
No
Do you smoke?
Yes
No
Statement
Please note: If you answered yes to any of the above, we recommend you gain medical clearance prior to the beginning of an exercise program
I hereby confirm that I undertake this exercise program under my own volition, in doing so I understand that any injuries I may incur as a result, will be my own responsibility and I will not hold Owners Corporation 509588A or Wyndham Water Recreation Centre Management Responsible with any claim of compensation, financial or otherwise *
Agree
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