St. Columba's Church Hall, Plas Newton, Chester, Cheshire, CH2 1SA, Tel: 01244 535788

Registered Charity 1123789

Gym Members - Self Declaration for non-cardiac patients
Please read the following questions carefully and answer as honestly as possible.

Contact Details

Conditions

Do you have, or have you ever had any of the following?

Frequent or severe headaches

Dizziness or fainting spells

Asthma or lung disease

Heart or vascular problems

High or Low blood pressure

Epilepsy or seizures

Diabetes

Stroke

Muscular disorders or complaint

Chest pains

Back complainte

Lower limb or joint problems

Has your doctor ever advised you not to partake in exercise?

(Women only) Are you or have you been pregnant in the past year

If you have answered yes to any of the questions above you are strongly recommended to seek medical advice before using gym facilities.

Emergency Contact Details

Declaration

I declare that I am not aware of any medical reason why I should not use the exercise facilities at this Centre.


I understand that I use the facilities at my own risk and that I agree to adhere to the centre's rules and etiquette and use the equipment in the manner I have been shown in order to prevent injury to myself or others and damage to the equipment.