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Disclaimer and Health Questionnaire

Personal Details & Emergency Contact

Your Name

Address

Number

D.O.B

How you heard about us?

Emergency Contact

Emergency Contact Number

Relation To You

Health Questions

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes No

Do you ever feel pain in your chest when doing physical activity or even when not doing physical activity?

Yes No

Do you have lose your balance due to dizziness or ever lose consciousness?

Yes No

Have you ever been diagnosed with a chronic medical condition?

Yes No

Do you have any bone or joint problems that could be made worse by a change in physical activity?

Yes No

Has your doctor ever said that you should only do medically supervised physical exercise or do you know of any other reason you should not undertake exercise or increase physical activity levels?

Yes No

Have you even been diagnosed with any brain condition or experienced concussion in the last 12 months?

Yes No

If you have answered YES to any of the above, please give more information:

Print Name

If Under the age of 16 - Parent / Guardian Name

CONTACT US

07941 062807

info@mackenziesgym.co.uk

WhatsApp Us

LINKS

LOCATION

Unit 7C, Francis Avenue

Wallisdown

BH11 8NX