First Name

Last Name

Email

Date of Birth

Mobile Phone

Emergency Contact Name

Emergency Contact Number

PRE-EXERCISE HEALTH SCREENING (Mandatory)

1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?

Yes

No

2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?

Yes

No

3. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

Yes

No

4. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?

Yes

No

5. Do you have any other conditions that may require special consideration for you to exercise?

Yes

No

I hereby acknowledge that the above information provided is correct.

St Clair Recreation Centre

Wellbeing Programs