MEDICIAL SCREENING

This information will remain confidential to KBPT, will be stored securely and will not be shared with any third parties other than in a medical emergency.

Personal Details

First Name

Last Name

Address

D.O.B.

How did you hear about KBPT?

If "Other" please give details

Have you suffered or are you suffering from any of the following? (please select more than one if needed)

Gout High blood pressure Stroke Dizziness or fainting Diabetes Glandular fever Epilepsy Liver/kidney condition Hernia Palpitations or chest pains Heart condition Stomach problems

If ticked, please give details

Has anyone in your family under the age of 60 suffered from heart disease or raised cholesterol?

Yes No

If yes, please give details

Are you taking any prescribed medication?

Yes No

If yes, please give details

Do you have any pain or injury, particularly in the region of the neck, back, knees or ankle?

Yes No

If yes, please give details

Have you had any operation during the past 12 months? Have you ever had joint replacement?

Yes No

If yes, please give details

Are you pregnant?

Yes No

Do you smoke?

Yes No

Is there any other aspect of your health not mentioned above that may affect the prescription of an exercise program?

Yes No

If yes, please give details

Declaration

I, the undersigned, have read, understood, and answered the above questions fully and truthfully. I am aware of my responsibilities to consult with my G.P. regarding my medical fitness to engage in exercise. I do hereby intend to be legally bound for myself and waive release of any and all rights and claims for damages I may have against the exercise professional administering the exercise program provided to me.

Signed

Check this box to sign declaration

Date

By signing this declaration you agree to our terms & conditions >