Physical Activity readiness form

Please complete the form below before taking part in any physical activity. If you answer yes to any questions or you are unsure then this will be discussed before we begin.

First Name

Email Address

Last Name

Date of Birth

Have you ever had any injury, illness, back or joint condition that you may feel could be aggravated by exercise? Suffered from Asthma, Diabetes, Epilepsy, Hernia, dizziness, Gout, circulation problems, Arthritis or an Ulcer? Have you ever had a Heart Condition, stroke, Palpitations, Murmurs or pains in the chest? Are you taking any prescribed medication?

Yes

Are you pregnant or have recently given birth?

Yes

Is there any other condition not mentioned in the above or are you aware of any other reason why you should not exercise or you are unsure about?

Yes

Initials

Today's Date

Declaration. I declare that to the best of my knowledge, the information given is correct and I know of no reason why I should not participate in fitness activities or training as advised by Tom Meehan Fitness.

Thank you!