Physical Activity Form

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Please complete the form below.

Physical Activity Form

Fullname

(Firstname and Lastname please)

Mobile Number

Emergency Contact Name

Emergency Contact Number

Has your GP advised you should only do physical activity recommended by a doctor?

Yes

Has your doctor ever said that you have a heart condition?

Yes

Do you feel pain in your chest when you do physical activity?

Yes

In the past month, have you had chest pain when you were not doing physical activity?

Yes

Do you lose your balance because of dizziness, or do you lose consciousness?

Yes

Do you have a bone or joint problem that could be made worse by a change in your physical activity?i

Yes

Is your doctor currently prescribing drugs (for example water pills) for you blood pressure or heart condition?

Yes

Do you know of any other reason why you should not do physical activity?

Photo & Video Consent

(see below)

Yes

I give my consent for my image and/or video to be used by Mucklagh Community Centre for promotional, educational, and community purposes, including on its website, social media platforms, printed materials, and other publications.

I give my consent to be added to the MCC Active Link WhatsApp group.

(see below)

Yes

The MCC Active Link WhatsApp group is used to share information about this class, upcoming activities, and social lunches at Mucklagh Community Centre. If you would like to receive these updates, please tick the box above.

I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction.

Previous Responses

*IF YOU HAVE ANSWERED YES TO ONE OR MORE*
1. Talk to your doctor BEFORE you become physically active.

2. Tell your doctor of your intention to exercise and which questions you answered ‘yes’ to. If at any stage your health changes, resulting in a ‘yes’ answer to any of the above questions, please seek guidance from a GP.