Gym Medical History Form

Personal Details

Full Name: *

Date of Birth: *

Phone (Cell / Mobile): *

Email: *

Age: *

Gender: *

Do you declare a disability? *

Please specify: *

Physician’s Name: *

Physician’s Phone: *

Medical History

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Do you now have, or have you ever had:

A definite or suspected heart attack? *

Please specify: *

A definite or suspected stroke? *

Please specify: *

Elevated blood pressure? *

Please specify: *

Any chronic illness or condition? *

Please specify: *

Difficulty with physical exercise? *

Please specify: *

Advice from physician not to exercise? *

Please specify *

Recent surgery (last 12 months)? *

Please specify: *

Pregnancy (now or within last 3 months)? *

Please specify: *

History of breathing or lung problems? *

Please specify: *

Muscle, joint, or back disorder, or any previous injury still affecting you? *

Please specify: *

Diabetes or metabolic syndrome? *

Please specify: *

Thyroid condition? *

Please specify: *

Cigarette smoking habit? *

Please specify: *

Elevated blood cholesterol? *

Please specify: *

History of heart problems in immediate family? *

Please specify: *

Hernia, or any condition that may be aggravated by lifting weights or other physical activity? *

Please specify: *

ANY ADDITIONAL NOTES/COMMENTS:

Body Mass Index (BMI)

Body Mass (kg): *

Height (metres): *

BMI:

I have answered the questions in this form accurately and completely. If any of the above conditions change, I will inform the club of those changes. I, knowingly and willingly, assume all risks of injury resulting from my failure to disclose accurate, complete, and updated information in accordance with the form.

Signature: *

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