NAME______________________________________________
ADDRESS :___________________________________________
PHONE : WORK :_________________________________
HOME :__________________________________
MOBILE :_________________________________
EMAIL :________________________________________
1.Has a doctor ever said 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 often feel faint, or have spells of severe dizziness ? YES / NO
5. Do you ever lose consciousness ? YES / NO
6. Do you have a bone or a joint problem that could be made worse by a change in your physical activity ? YES / NO
7. Has a doctor ever said that your blood pressure is too high ? YES /NO
8. Is your doctor currently prescribing drugs for your blood pressure or heart condition ? YES / NO
9. Do you know of any other reason why you should not do physical activity ? YES / NO
10. Do you currently participate in any regular activity program designed to improve or maintain fitness ? YES / NO
If yes, what activity do you participate in ?_________________________________________________
11. Do you currently have a disability or a communicable disease ? YES / NO
If yes, please specify :_________________________________________________________________
12. Are you using any other medication ? If so, please specify:______________________________________
If you answered NO to all the questions above, it gives a general indication that you may participate in physical and aerobic fitness activities. The fact that you answered NO to the above questions is no guarantee that you will have a normal response to exercise. If you answered YES to any of the above questions, then you may need written permission from a licenced physician before participating in SHASHIDO fitness activities.
Please note : If you contract a communicable disease, it is your responsibility to inform the Proprietor of this condition, and your membership may be suspended until this condition is cured, or in a state of remission. It is strongly recommended that everyone over 30 years of age obtain a medical clearance prior to commencing SHASHIDO fitness activities.
PRINT NAME_____________________________________________________
SIGNATURE_____________________________________________________________
SIGNATURE (Parent/guardian) :________________________________________
DATE :_______________________
