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?YesNo

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

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

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

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

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

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

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

Submit

*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.