Health Questionnaire

First Name*

Last Name*

Date of Birth*

Address*

Address 2*

City*

Post Code*

Country
AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d’IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor-Leste)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFijiFinlandFranceGabonThe GambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorth MacedoniaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Mobile Number*

Email*

A little about you i.e your current level of fitness, type of training you prefer and goals.*

Which package(s) are you interested in?
Corporate Fitness6 Week Transformation CampLive Stream FitnessSF BootcampsSimFit 666PT - Face to Face or Online

Has your doctor ever said that you have a heart condition and that you should only do physical activities recommended by a doctor?
YesNo

Do you feel pain in your chest when you do physical activities?
YesNo

In the past month, have you had a chest pain when you were not doing physical activities?
YesNo

Do you lose balance because of dizziness or do you ever lose consciousness?
YesNo

Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in your physical activity?
YesNo

Is your doctor currently prescribing medication for your blood pressure or heart condition?
YesNo

Do you know of any other reason why you should not take part in physical activity?
YesNo

If yes please comment below

Do you have any allergies?
YesNo

Do you suffer with epilepsy, asthma or have diabetes?
YesNo

Are you pregnant?
YesNo

If you answered yes to one or more of these questions:
you should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.

If you answered no to one or more of these questions:
It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A fitness appraisal can help determine your ability levels.

Confirm
I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.

Do you consent to any photos taken of yourself during the sessions to be used for SimFit social media and marketing?
YesNo

From time to time can we send you marketing via email?
YesNo

Declaration
In consideration of being allowed to participate in the activities and programmes at SIMFIT LTD, I acknowledge that:

1. I am aware of and understand the potential risks and dangers associated with physical activity including the use of equipment and I am voluntarily participating in these activities with knowledge of the risks and dangers involved.

2. I understand that exercise and fitness activities in and outdoors involve a risk of injury and even death and that I am voluntarily participating in these activities and using equipment and facilities with knowledge of the dangers involved. I hereby agree and expressly assume all and any risks of injury or death.

3. I know of no reason why I should not participate in any of the programmes and activities at SIMFIT LTD. I hereby declare myself free of any condition, disease, infirmity or illness that may affect my participation. I agree to inform a member of staff and where appropriate provide written consent from my doctor should such a condition or complaint arise before continuing with any activity.

4. I agree to abide by all oral notices regarding safety whilst at a SIMFIT LTD class. I am aware I have the opportunity to ask questions about the activities, general use of equipment and other related issues at class. If I choose not to take the advice or to disregard any advice given, I do so voluntarily and accept liability for all resulting injuries or damage.

5. I do hereby waive, release and discharge SIMFIT LTD from any and all responsibility or liability for injuries or damages resulting from my participation in any activities or my use of equipment or facilities in the above mentioned activities.

6. This questionnaire has been completed accurately to the best of my knowledge and belief.

I have read, understood and completed this questionnaire and agree to be bound by its conditions.

Please e-sign your name in the space below.