Medical and lifestyle questionnaire
PRE-SCREENING
Name
Telephone Number
Emergency Contact
Doctor
Address
DOB
Emergency number
Doctor Telephone Number
Occupation
Physical activity history
In the last year how often have you participated in physical activity?
Is there anything in your medical history that could affect your capacity to exercise?
Medical history
Tick the box if you have experienced any of the following, past or present
If you have ticked any of the boxes please give further details
Are you on any medication? If so please give details
What (if any) has been your experience with running so far (leave blank for Park Fit)
I confirm that I declare myself fit to run and I understand that participation in this group is entirely at my own risk. I have answered all of the questions correctly and all medical and health considerations have been disclosed. Please note that it is your responsibility to inform your instructor of any medical condition that may affect your health whilst under their instruction
Thank You
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