Your online gym induction

Name *

First Name

Last Name

Completed video induction *

YES

DOB *

MM

DD

YYYY

Date *

MM

DD

YYYY

Please read the following questions carefully and select next to the appropriate statement this applies. Answer all questions honestly and to the best of your ability.

Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or that you should only do physical activity recommended by a doctor?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Have you ever been told by a doctor that you have bone, joint, or muscle problems that could be made worse by physical activity?

Do you have a diagnosed illness that could be made worse by physical activity?

Is your doctor currently prescribing medication for your blood pressure or heart condition?

Do you know of any other reason why you should not do physical activity?