Physical Activity Readiness Questionnaire First Name:
Surname:
Emergency Contact details: Name: Number: Please answer all questions honestly. All information is kept confidential. Medical Questionnaire 1.
Yes
Have you ever had a stroke?
When: 2.
Treatment:
Have you ever had heart surgery?
When: 3.
Treatment:
Treatment:
Type II
Treatment/Medication:
Do you have high blood pressure?
When Diagnosed: 6.
Treatment/ Medication:
Do you have angina or suffer from chest pains?
GTN Spray/tablet: Yes 7.
Rehab:
Do you have diabetes?
Type I 5.
Rehab:
Have you ever had a heart attack?
When: 4.
Rehab:
No
Frequency of use:
Do you have any respiratory condition?
Condition:
Treatment/ Medication:
8.
Do you have any mental health issues like anxiety/depression?
9.
Do you have epilepsy?
Medication: 10. Do you have arthritis or osteoporosis? Type:
Medication:
11. Are you currently taking any other medication? Details: 12. Do you smoke? Ex-smoker?
Limitations:
No
13. Do you suffer from any muscular or joint pain? Problem:
Treatment:
14. Have you had your cholesterol measured? Result:
Only complete the following if having a program written by an instructor: Have you used a gym before?
When & why stopped:
Likes & dislikes: (circle likes) Treadmill
Cross Trainer
Bike
Stepper
Rowing Machine
Recumbent Bike
Other:.............................................................................................................................................................................. What are your goals? (Please circle) Lose Weight
Lose inches
Tone
Feel Better
Strengthen
Get Fitter
Other:............................................................................................................................................................................. Is there a particular area you would like to focus on? (Please Circle) Chest
Back
Arms
Waist
Stomach
Legs
Whole body
Other:............................................................................................................................................................................... How many times per week are you prepared to commit to the gym?: (Please Circle) 1
2
3
More than 3
I have read & understood that all of the following information has been answered honestly to the best of my knowledge & that I accept exercise carries with it an element of risk, however small. If my health changes, I will inform a member of staff. Signature: ......................................................................... Date: ................................................................... Instructor Notes:
I certify that the above person has demonstrated safe operations of Peebles Hydro Leisure Clubs fitness equipment. Instructor Signature: …………………………………………………… Date: ………………………………………………………… Data Protection: Peebles Hydro Leisure Club will store & use the information about you which you provide on this form (‘your information’) strictly in accordance with the data protection Act 1988. The club will use your information for health & safety purposes and, if otherwise, then only to the extent necessary for carrying out any of our statutory functions as a hotel.