BOXERCISE LINCOLN HEALTH FORM

Member Name: ______________________DOB:____ ___Date______________
When planning to undertake physical activity, you should start by answering the questions below. If you are in any doubt, consult with your G.P. before commencing exercise. 
Please read the questions carefully and answer them honestly by circling YES or NO. 


HEALTH SCREENING QUESTIONNAIRE 
1. 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 
2. Do you feel pain in your chest when you do physical activity? YES / NO 
3. In the past month, have you had chest pain when you were not doing physical activity? YES / NO 
4. Do you lose balance because of dizziness or do you ever lose consciousness? YES / NO 
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity level? YES / NO 
6. Have you ever had any problems with your back? YES / NO 
7. Is your doctor currently prescribing any medication for your blood pressure or a 
heart condition? YES / NO 
8. Is there any family history of heart disease, stroke, raised cholesterol or 
high blood pressure? YES / NO 
9. Do you suffer from diabetes/epilepsy/asthma? YES / NO 
10. Are you pregnant, or have you given birth in the last six weeks? YES / NO 
11. Do you have, or have you had any illnesses recently? YES / NO 
12. Have you recently had surgery? YES / NO 
13. Do you know of any other reason why you should not do physical activity? YES/NO 

If you have answered ‘yes’ to any of the questions above, please can you give brief details: (We may require you to obtain written consent from your G.P. before agreeing to allow you to undertake any physical exercise in the gym) 

Safeguarding
Before you sign this form have you being made aware of the safeguarding /Harassment policies and procedures? Please ask a member of staff for information or visit www.boxerciselincoln.co.uk for information 

Photos/video and social media 
Sometimes we advertise Boxerciselincoln on the internet through websites and social media sites can you please circle below your personal wishes

I DO NOT WISH TO BE PHOTOGRAPHED/RECORDED OR USED ON SOCIAL MEDIA/WEBSITES OR ADVERTISING   

I HAVE NO ISSUES TO BE PHOTOGRAPHED/RECORDED OR USED ON SOCIAL MEDIA/WEBSITES OR ADVERTISING   
I have read and fully understand the exercise readiness questionnaire I confirm that to the best of my knowledge, the answers are correct and accurate. I know of no reason why I should not participate in an exercise workout. I understand I would be using the health and fitness facilities entirely at my own risk and waive any legal recourse for damages to myself or property arising from my participation 
CLIENT DECLARATION 
I have understood and answered all of the above questions honestly. I understand that I should not exercise if I feel unwell and that if my health changes I should inform my instructor. 

Contact_____________________________Emergency contact_____________
Signed Member: _____________________Staff check:_________________ 
Date: _____________________
Clients under 16 years of age parents/guardians signature_______________________

BOXERCISE LINCOLN HEALTH FORM

Member Name: ______________________DOB:____ ___Date______________
When planning to undertake physical activity, you should start by answering the questions below. If you are in any doubt, consult with your G.P. before commencing exercise. 
Please read the questions carefully and answer them honestly by circling YES or NO. 


HEALTH SCREENING QUESTIONNAIRE 
1. 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 
2. Do you feel pain in your chest when you do physical activity? YES / NO 
3. In the past month, have you had chest pain when you were not doing physical activity? YES / NO 
4. Do you lose balance because of dizziness or do you ever lose consciousness? YES / NO 
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity level? YES / NO 
6. Have you ever had any problems with your back? YES / NO 
7. Is your doctor currently prescribing any medication for your blood pressure or a 
heart condition? YES / NO 
8. Is there any family history of heart disease, stroke, raised cholesterol or 
high blood pressure? YES / NO 
9. Do you suffer from diabetes/epilepsy/asthma? YES / NO 
10. Are you pregnant, or have you given birth in the last six weeks? YES / NO 
11. Do you have, or have you had any illnesses recently? YES / NO 
12. Have you recently had surgery? YES / NO 
13. Do you know of any other reason why you should not do physical activity? YES/NO 

If you have answered ‘yes’ to any of the questions above, please can you give brief details: (We may require you to obtain written consent from your G.P. before agreeing to allow you to undertake any physical exercise in the gym) 

Safeguarding
Before you sign this form have you being made aware of the safeguarding /Harassment policies and procedures? Please ask a member of staff for information or visit www.boxerciselincoln.co.uk for information 

Photos/video and social media 
Sometimes we advertise Boxerciselincoln on the internet through websites and social media sites can you please circle below your personal wishes

I DO NOT WISH TO BE PHOTOGRAPHED/RECORDED OR USED ON SOCIAL MEDIA/WEBSITES OR ADVERTISING   

I HAVE NO ISSUES TO BE PHOTOGRAPHED/RECORDED OR USED ON SOCIAL MEDIA/WEBSITES OR ADVERTISING   
I have read and fully understand the exercise readiness questionnaire I confirm that to the best of my knowledge, the answers are correct and accurate. I know of no reason why I should not participate in an exercise workout. I understand I would be using the health and fitness facilities entirely at my own risk and waive any legal recourse for damages to myself or property arising from my participation 
CLIENT DECLARATION 
I have understood and answered all of the above questions honestly. I understand that I should not exercise if I feel unwell and that if my health changes I should inform my instructor. 

Contact_____________________________Emergency contact_____________
Signed Member: _____________________Staff check:_________________ 
Date: _____________________
Clients under 16 years of age parents/guardians signature_______________________