Fitness Appraisal - Health and Lifestyle Evaluation

Personal Details
Contact Numbers:
   
   
Personal Objectives (Please tick)
Medical Profile
Yes No
Do you have any injuries? Yes No
Please provide details of any medications that you are currently taking:

Coronary Heart Disease Risk Factors
 
Gender:
Male Female
Do you have a family history of heart disease?



 
Diabetes:
 
Weight:




 
Smoking:




 
Fitness:




Blood Pressure:
Systolic:



Dystolic:



Emergency Contact Details
Declaration

I hereby declare that I have completed the required medical questionnaire and given my medical history to the best of my knowledge.

I declare and warrant that I am in a good state of health and that there is no reason whatsoever that could be regarded as a restriction upon or an impediment to my application for membership. I acknowledge and declare that during all such times as I am on the premises (or it's surrounds) both my property and my person shall be at my own risk and I will not hold Trench Sportz Pty Ltd (or it's employees) liable for any personal injury of loss of property however causes.

 

 

 

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