Pre-Exercise Questionnaire - Inner West Council

Please select your membership type* - required

Leichhardt Park Aquatic Centre member

Fitness Passport member

Youth Fit entry

Casual entry

Please enter your membership number, if applicable

First name*

Surname*

Date of birth*

Email*

Address*

Suburb*

Postcode*

Phone number*

Emergency contact name*

Relationship to you*

Emergency contact phone*

If you are under the age of 16, please have a parent or guardian complete this form with you and provide their details below.

Parent/guardian first name

Parent/guardian surname

Parent/guardian phone number

Parent/guardian email

Medical considerations

It is our professional duty of care to ask all participants, no matter what age, to complete the following questions.

Have you ever, or do you now have:

Any family member under 60 whom has suffered heart disease, stroke or raised cholesterol?* - required

Yes

Are you on prescribed medication that may affect your ability to exercise?* - required

Yes

Have you given birth within the last six weeks?* - required

Yes

Do you have any infections or infectious diseases?* - required

Yes

Have you been hospitalised recently?* - required

Yes

Are you pregnant?* - required

Yes

If you have answered yes, or are not sure to any of the above, please see your Doctor and ask for a medical certificate prior to commencement of any exercise program.

If you have ticked any of the above, please ask and Instructor for guidance before starting on an exercise program.

If requested by a staff member, please enter your blood pressure reading here

Please elaborate on any of the above that may be relevant to your exercise program

Are there any other injuries or conditions that may affect your exercise program

Please read the following advice carefully:

Ask any gym staff member to guide you into the most suitable class or program. Work at a low level on your first visit and concentrate on learning to do the exercise properly. On each visit you will be able to work a little harder. Be sure to limit yourself to a pace where you can still talk comfortably.

Should you suffer any injury, illness or conditions in the future please tell us before you commence your program. It is recommended that all persons over 40 should have a medical assessment including an exercise ECG and cholesterol / lipid count by their doctor before starting a program.

Disclaimer: By submitting this form I recognise that the instructor is not able to provide me with advice with regards to my medical fitness and that this information is used as a guideline to the limitations of my ability to exercise. I have answered the questions to the best of my ability and understand the advice above.

If you are a parent/guardian of the person who has completed this form, please tick this box to confirm you consent to them participating in a guided fitness program.

Mandatory field(s) marked with *