Health and Safety Form

Date of Birth (Min age of 16) *

First Name *

Last Name *

Emergency Name *

Emergency Tel *

1. Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse with exercise? * Yes No

2. Do you have high blood pressure? * Yes No

3. Do you have low blood pressure? * Yes No

4. Do you have Diabetes Mellitus or any other metabolic disease? * Yes No

5. Has your doctor ever said you have raised cholesterol (serum level above 6.2mmol/L)? * Yes No

6. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? * Yes No

7. Have you ever felt pain in your chest when you do physical exercise? * Yes No

8. Is your doctor currently prescribing you drugs or medication? * Yes No

9. Have you ever suffered from unusual shortness of breath at rest or with mild exertion? * Yes No

10. Is there any history of Coronary Heart Disease in your family? * Yes No

11. Do you often feel faint, have spells of severe dizziness or have lost consciousness? * Yes No

12. Do you currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women)? * Yes No

13. Do you currently smoke? * Yes No

14. Do you NOT currently exercise on a regular basis (at least 3 times a week) and/or work in a job that is physically demanding? * Yes No

15. Are you, or is there any possibility that you might be pregnant? * Yes No

16. Do you know of any other reason why you should not participate in a program of physical activity? * Yes No

If YES please give details

Do you currently exercise? If so what do you do and how often?

How did you hear about the Bootcamp?

I hereby state that I have read, understood, and answered honestly the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance exercise, and stretching. I realise that my participation in these activities involves the risk of injury.I agree to advise the Instructor if there are any changes in my medical condition and understand that the Bootcamp instructor will not be liable for any injury or illness that may occur.

Confirm Assumption of Risk * Yes No