Pre-exercise registration survey Newly-registered participants for Council recreation programs must complete this registration survey prior to their first class. Name* - required Date of birth* - required e.g. 1/1/1970 Gender Emergency contact name* - required Emergency contact phone* - required Select the exercise program(s) you* - required Mums Get Active - Post-natal pilates Zumba Gold - Ashfield Zumba Gold - Marrickville Women's Dance Fit Walking Basketball Personal health history 1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?* - required Yes No 2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?* - required Yes No 3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?* - required Yes No 4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?* - required Yes No 5. If you have diabetes (Type I or Type II) have you had trouble controlling your blood glucose in the last 3 months?* - required Yes No 6. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?* - required Yes No 7. Have you had any recent operations or injuries?* - required Yes No If you answered YES to any of the first 6 questions under "personal health history", please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise. I believe that to the best of my knowledge all the information I have supplied within this survey is correct. This tick box is an acknowledgement of my signature.* - required Mandatory field(s) marked with * Important: This survey is self-evaluated. It does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Council for any loss, damage or injury that may arise from any person acting on any statement or information contained in this survey.
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