Health Questionnaire and Liability Waiver

Physical conditions: existing or in the last 5 years *

Surgery Heart Condition Breathing or lung problem (inc Asthma) Dizziness Muscle, joint or back problem Diabetes/Epilepsy Pregnant or given birth in the last 3 months High blood pressure Severe Allergies Arthritis/Osteoporosis None

Please give details of any of the above conditions or any other reasons that may affect you exercising: *

Have you ever needed to speak to your GP about exercise? *

Yes No

If yes, please give details *

Are you currently taking any prescription medications? *

Yes No

If yes, please give details *

Do you smoke? *

Yes No

How many units of alcohol do you drink in an average week? *

Describe your job *

Sedentary Active Physically Demanding

If 'current member' or 'other' please give details: *

Emergency contact details - Name *

Relationship to you *

Declaration. I have read and fully understand this questionnaire and confirm that, to the best of my knowledge, the answers given by me are correct and accurate. I know of no reason why I should not participate in any form of physical exercise or activity suggested to me by the fitness coach. I acknowledge that any suggestions from the coach regarding exercise, healthcare and nutrition are neither diagnostic nor prescriptive. I am also aware of the potential risks of injury and death through exercise, and I am voluntarily participating in these activities with that knowledge. I agree to notify the coach of any future changes to the above answers before continuing exercise. I give permission for you to take and use my photograph to post on www.crossfitavon.com and/or for promotional material. By typing your name in this box you are digitally signing this document. Your typed name carries the same weight as a paper signature. Name: *

New Athlete Health Questionnaire and Liability Declaration

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