Just Dunn It Charity Fitness Event

Pre-Exercise Questionnaire First Name Address: Postcode: Email Address: Certain Medical issues may indicate that you should not take part in exercise unless you have first obtained your doctors approval. Please tick the boxes below if any of the following medical issues apply to you unless you have already obtained doctors approval to exercise. If any of the following medical issues apply to you and you have not obtained your doctors approval to exercise you must obtain your doctors approval before we can permit you to exercise in our centre. Contact Number: Surname

1. You have a heart condition and your doctor has recommended that you only exercise in 2. 3. 4. 5. 6. 7.
a medically supervised programme You have on one or more occasions lost consciousness or fallen over as a result of dizziness You experience unexplained chest pains at rest or while active You have been diagnosed with a severe bone or joint problem that could be made worse by exercising You are currently being prescribed medication for high blood pressures a heart condition or other serious illness You are pregnant or have given birth in the last three months There is another reason, not mentioned above, why you should only exercise in a medically supervised programme (e.g. uncontrollable diabetes or epilepsy)

Involvement in sports and related activities carries a risk of personal injury or death. Participate at your own risk! Declaration If you have any questions regarding this pre-exercise questionnaire please speak to a Nuffield Health Team Member. If any of the answers to the above questions change or for any other reason you are unsure at any time whether as a result of your state of health you should exercise please seek the approval of your doctor and inform Nuffield Health before exercising. I have read and fully understand this pre-exercise questionnaire and confirm that the answers given by me are correct and not misleading. I know of no reason why I should not participate in any form of exercise or any other activity available at any of our centres. IMPORTANT: Nuffield Health may use the information you have provided in this health history and any other information provided by you relating to your mental and physical condition to ascertain whether physical exercise is appropriate for you and if necessary to seek further information from your doctor or other specialist. By signing this declaration, I agree to the use of my information as started in this data statement. Guest Signature: _____________________________________________________________________________ Guest Name: ________________________________________________________________________________

Date: ______________________________________________________________________________________