Day Pass – Application

Personal Contact Details:

Your First Name Name:

Your Last Name Name:

Your House Name or Number:

Your Street Name:

Your Town:

Your Postcode:

Your Date Of Birth:

Your Mobile Number

Your Email Address:

Regular exercise is associated with many health benefits. Increasing physical activity is safe for most people. However,
some individuals should check with a physician before they become more physically active. Completion of this
questionnaire is a first step when planning to increase the amount of physical activity in your life. Please read each
question carefully and answer every question honestly:

Health Questionnaire:

1) Has a physician ever diagnosed you with a heart condition and indicated you should restrict your physical activity?
YesNo

2) Do you frequently get pains in your chest?
YesNo

3) Do you have a bone or joint problem that has been aggravated by exercise or might be made worse by exercise?
YesNo

4) Do you ever faint or get dizzy and lose your balance?
YesNo

5) Do you have an injury or orthopaedic condition (such as a back, hip, or knee problem) that may worsen due to a change in your physical activity?
YesNo

6) Has your doctor ever told you that you have high blood pressure?
YesNo

7) Are you pregnant or Have you given birth in the last 3 months?
YesNo

8) Do you or have you ever had diabetes?
YesNo

9) Have you had any surgery in the last three months?
YesNo

10) Are you 65 years of age or older and not used to being very active?
YesNo

11) In the past 24 hours, have you experienced any of the following symptoms or signs? Nasal
congestion, fever (38°C/100°F), shortness of breath, headache, unexplainable fatigue, pink eye
(conjunctivitis), change in or loss of sense of taste or smell, any digestive symptoms (diarrhoea, vomiting
or abdominal pains)?
YesNo

12) Have you been in close contact with anyone with a fever and/or shortness of breath?
YesNo

13) Have you had COVID-19 and has it been diagnosed in the past 7 days (in a lab)?
YesNo

14) Have you been in direct contact with anyone with respiratory illness or a confirmed or probable case of COVID-19?
YesNo

15) Are you quarantined because you: – Have been in direct contact with someone diagnosed with COVID-19? – Have travelled outside of the country or have been in close contact with anyone who has travelled outside of the country, to a high-risk region, in the past 14 days?
YesNo

*IMPORTANT* If you have answered “YES” to any of the above questions you will be required to seek medical advice from your GP and attend a compulsory induction before using the fitness suite. Once you have done this please re-complete this form again.

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 that 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 an instructor.

I agree

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