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Pre-exercise screening

Please take a few minutes to fill in this form. This information will be used to assess your health and fitness and enable us to ascertain to what capacity you can participate in our exercise programs and services. Please note this form is valid for one year from date of completion.

Personal details
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Date of birth*
DD slash MM slash YYYY
Gender*
Emergency contact
Name*
First Last
Relationship*
Phone*
Medical history

Do you have any of the following medical issues, or have you ever experienced any of the listed symptoms or complaints:
A heart condition?*
- Yes
- No
A stroke?*
- Yes
- No
An asthma attack, which in the past 12 months has required immediate medical attention?*
- Yes
- No
Diabetes (type I or II) where you have had trouble controlling your blood glucose in the last 3 months?*
- Yes
- No
Any diagnosed muscle, bone or joint problems which could be made worse through exercise?*
- Yes
- No
Unexplained pains in your chest at rest or during physical activity?*
- Yes
- No
Loss of balance while exercising, due to dizziness or feeling faint?*
- Yes
- No
Any other condition or illness that may make it dangerous for you to participate in physical activity or exercise?*
- Yes
- No
Any other condition or illness that may make it dangerous for you to participate in physical activity or exercise?*
- Yes
- No
Please provide details if you marked 'yes' in any of the above questions.
If you answered yes to any of the above, you will not be able to participate in any physical activity at this Centre or utilise the facilities until a doctor has been consulted, and a medical certificate or approved letter has been provided, stating participation is allowed.
- Medical clearance received and attached
Please read and sign this section:*
- I state the information supplied by me is true and correct;
- I understand staff will rely on the accuracy of this information before allowing me to use the facilities & equipment;
- I understand I undertake all exercise and/or use the gym/aerobics facilities at my own risk;
- I understand it is in my best interest to exercise within my abilities and in the safest manner possible;
- I recognise that staff are not able to provide me with medical advice with regard to my medical fitness, and understand that the information provided on this form is used as a guideline to assess any limitations in my ability to exercise;
- I understand that should I suffer from any injury or illness in the future that may affect my ability to exercise, I should inform the centre staff;
- Casual visitors are ‘members’ for the period of their single visit, and must comply with entry conditions at the Facility they are using.
Induction*
- I would like a complimentary induction with a qualified trainer
- I am competent in the use of the fitness equipment and decline an induction with a qualified trainer.
Member signature*
Staff signature*
Date*
DD slash MM slash YYYY
Uni Fitness (Student Guild) and Aquatic Centre (Griffith Sport) collects, stores, and uses personal information only for the purposes of administering Student Guild and Griffith Sport programs and services. The information collected will not be disclosed to third parties without your consent, except to meet government, legal or other regulatory authority requirements. For further information, consult the University’s Privacy Plan at griffith.edu.au/privacy-plan

Griffith University’s Student Guild supports the University’s commitment to the United Nations Sustainable Development Goals (SDGs) and to a sustainable future for all through quality and inclusive education.

The Griffith University Gold Coast Student Guild acknowledges the people who are the traditional custodians of the land and pays respect to Elders, past and present, and extends that respect to all Aboriginal and Torres Strait Islander peoples. The Gold Coast campus is situated on the land of the Yugambeh/ Kombumerri peoples.

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