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INJURY FORMS
INJURY FORM
Summerhill GFC Facilities
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Address
*
Date of Birth (DD/MM/YYYY
*
Phone
*
Email
*
Are You Currently Excerising?
*
YES
NO
Type of exercise?
Frequency of exercise?
What do you wish to achieve with the use of the gym ? Please list your goals:
Are you currently seeing a medical practitioner for any injuries or illness?
*
YES
NO
If YES, please specify:
Do you currently have any medical conditions?
*
YES
NO
Do you currently have any medical conditions?
*
YES
NO
In the past 6-12 months, have you undergone any surgical procedures?
*
YES
NO
If YES, please specify:
Do you have a family history of heart disease?
*
YES
NO
Have you ever suffered from a heart condition?
*
YES
NO
Have you ever suffered from any of the following? (Please Tick All Relevant or NONE)):
*
Chest Pains
Chest Tightness
Shortness of breath from exertion
Heartburn
NONE
Do you have high blood cholesterol?
*
YES
NO
Do you have any type of diabetes?
*
YES
NO
Do you have a pace maker?
*
YES
NO
Do you take any prescribed medication?
*
YES
NO
If YES, what type and why?
Do you take any nutritional supplements?
*
YES
NO
If YES, what type and why?
Is there a family history of prostate cancer, breast cancer or colon cancer?
*
YES
NO
If YES, please specify:
Do you have or have you ever had any of the following conditions: (Please Tick All Relevant or NONE)
*
High blood pressure
Stroke
Asthma
Gout
Heart murmur
Diabetes
Epilepsy
Chrone’s Disease
Recent weight gain/loss
Glandular Fever
Dizziness
Lung Disease
Sinus Problems
Stomach Ulcer
Arthritis
Drug/Alcohol Problems
Depression
Thyroid Problems
NONE
Any other symptoms or conditions that concern you?
Do you Smoke?
*
YES
NO
If YES, please specify how many per day:
Are you pregnant now or have you recently been pregnant?
*
YES
NO
Do you have any muscular injuries or pain?
*
YES
NO
If YES, please specify:
Do you have any joint injuries?
*
YES
NO
If Yes please specify or click NONE:
*
Back
Ankles
Neck
Elbow
Hips
Shoulders
Knees
NONE
Do you suffer from arthritis?
*
YES
NO
Do you suffer from osteoporosis?
*
YES
NO
Do you have any reason why you should *NOT* exercise in the gym?
*
YES
NO
On a scale of 1-10 (1 = no stress, 10= overwhelming stress), how would you rate your current WORK stress levels?
Selected Value:
0
On a scale of 1-10 (1 = no stress, 10= overwhelming stress), how would you rate your current PERSONAL stress levels? (copy)
Selected Value:
0
I have read and agree to the Terms of Service Agreement listed below.
*
Before participating in the Summerhill GFC Gym you must disclose any injuries or medical conditions that may be affected by participating in this program.
Before embarking on any fitness or exercise programme you should seek medical advice from your GP.
Terms and Conditions
1. Your personal data as provided on this form will be used for the purpose of membership and will not be used for any other purpose. The Data Controller for the personal data provided on this form is the club. For further information in relation to your personal data please contact club secretary.
2. Summerhill GFC Instructors accept no responsibility for any loss, damage or injury to any participants / non participants, or to the personal property of any participant / non participant (or to any person accompanying whether by invitation or otherwise) who enters upon the club premises for whatever purpose and whether such loss, damage or injury is caused directly or indirectly by the Club
2. Every participant in the Summerhill GFC Gym warrants that to the best of their knowledge and belief they are suffering from no physical disability or illness whether or not such disability or illness is or may be affected by exercise of whatever degree, and further warrants to advise the Instructors if, after becoming a member they such suffer from such disability or illness and every applicant by their signature agrees to indemnify the Instructors class in respect of any disability or illness whether suffered in the class or otherwise.
3. By participating in Summerhill GFC every participant agrees to abide by our rules and regulations and understands the club reserves the right to refuse entry should these be contravened.
4. Rates for services are subject to change.
5. Appropriate clothing is required at all times during sessions
6. Summerhill GFC respects your privacy. All personal details are treated as confidential and we will not share or redistribute your information with any third party.
7. I understand that occasionally the gym maybe unavailable due to collective team training.
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