Client Health Declaration

Please fill out the following form.

First name

Last name

Address

Phone Number

Emergency Contact (Name)

Emergency Contact (phone number)

Email

Date of birth

Day

Month

Year

Occupation

Do you have any injuries ? Past or Present

Yes

No

If you answered Yes, please give full details

Do you have an ongoing medical condition or illness ?

Yes

No

If you answered Yes, please give full details and medical information

Are you taking any medication?

Yes

No

If you answered yes please supply full information

Please list any regular physical activities

If other please specify

Have you given birth in the last 6 months?

Yes

No

If, so please provide date and any medical information you think necessary

I understand the various risks associated with an exercise programme and it is my desire to participate. I have not withheld any relevant information regarding my physical condition which may affect me during or following a session, and I will notify you of any other injuries that may occur. (required)

Initials

How did you hear about us

Would you like to receive our Newsletter? The Newsletter goes out every 6 weeks and is the main source of news, updates and offers

Yes

No

Client Details Form

Client Health Declaration