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Date Of Birth
Do you suffer from any of the following?
None of the below
1. Has your doctor ever said that you have a heart condition and/or that you should only do physical activity recommended by a doctor?
2. Do you feel pain in your chest at rest or when doing any physical activity?
3. Has your doctor/nurse ever said you have high blood pressure?
4. Do you ever lose consciousness or your balance due to dizziness?
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity or exercise training?
6. Do you suffer shortness of breath at rest or with mild exertion?
7. Are you pregnant or have you given birth in the last 3 months?
8. Is there a history of heart disease in your family? (Mother, father, sister or brother have had a heart attack or died suddenly before the age of 55)
9. Do you suffer from epilepsy?
10. Do you smoke or have you stopped smoking in the last six months?
11. Do you take any prescription medications (apart from the contraceptive pill) e.g. an inhaler for asthma?
12. Do you know of any other reason why you should not do any physical activity?
13. Do you have any questions you would like answered before exercising?
If you answered yes to any of the above please provide details
CHOOSE YOUR MEMBERSHIP
First Timer - Trial Class
Pay As You Go - Prepaid Drop in
12 Session Package - 3 Classes Per Week
8 Session Package - 2 Classes Per Week
4 Session Package - 1 Class Per Week
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