Name*

First Last

Email*

Date of Birth*

Gender*

Male
Female

First line of your address*

Street Address

Address line 2 if required

Address Line 2

City*

City

Post code*

ZIP / Postal Code Country

Where have you previously worked out*

What are you fitness goals?*

Do you have high blood pressure?*

Yes
No

Do you currently experience any pains in your chest when you undertake physical activity?*

Yes
No

Have you previously suffered from chest pains during physical activity?*

Yes
No

Do you lose your balance because of dizziness?*

Yes
No

Do you ever lose consciousness?*

Yes
No

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

Yes
No

Are you currently taking any prescribed medication excluding the contraceptive pill?*

Yes
No

Are you currently taking any prescribed medication?*

Yes
No

Do you know of any reason why you should not be undertaking physical activity?*

Yes
No

Please document any injuries (or anything else that may be a concern) that should be brought to our attention:*

Doctors consent

If you have answered any of the above questions with a yes you will need to consult with your GP BEFORE you start becoming more physically active. We will need written confirmation from your GP before you begin using the gym.

Doctors consent required
Consent NOT required

Declaration

I have read, understood and completed the above questionnaire and acknowledge that there are risks and dangers inherent in physical exercise and duly undertake the activity at my own risk. Any liability on the part of the operators is excluded unless negligence can be proven. I agree to observe the rules and conditions of membership. I also acknowledge that I must not use any piece of equipment for which I have not been shown how to use by an instructor. I confirm that the information which I have provided is correct at this time and should I become aware of any relevant changes to my health or condition, I will inform a member of the AMP coaching team.

I agree
I disagree