Fitness Assessment Form Page 2
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6Indemnity
I understand that;
As part of this assessment I will be asked questions about my medical and activity history,
and may be asked to perform a range of physical activities for the purposes of assessing
my physical fitness
I do not need to answer any questions or do anything, but the information I give or
withhold will affect the design of my programme, and the trainers cannot be held
responsible for failing to consider a condition I did not make them aware of
The trainer has no expertise in the medical field and cannot diagnose or detect any
serious medical problems and if something concerns me I should see a medical
professional
If any medical condition raises concerns about my readiness to undertake physical
training, I will be directed to a medical professional, so that they can prohibit or
recommend various kinds of training for my health and safety
All information given here is entirely confidential, and will only be divulged as necessary
for my health and safety
Signature: __________________________________________
Date: ______________________________
Assessing trainer: ___________________________________
Date: ______________________________
MEDICAL HISTORY
Do you have a current or previous history of any of the following conditions?
Comments
Hypertension Y/N _________________________
Thyroid Disorders Y/N ______________________
Previous Heart Attack Y/N _________________
Renal or Liver Disease Y/N _________________
Angina Y/N _______________________________
Osteoporosis Y/N __________________________
Claudication Y/N _________________________
Arthritis Y/N _______________________________
Heart Murmur Y/N _________________________
Back Pain Y/N _____________________________
Previous Stroke Y/N ________________________
Recent Surgery Y/N _______________________
Epilepsy Y/N ______________________________
Previous/Current Pregnancy Y/N ___________
Asthma Y/N _______________________________
Previous/Current Smoker Y/N ______________
Emphysema Y/N __________________________
Currently receiving treatment from a health
care practitioner of any kind Y/N
Chronic Bronchitis Y/N _____________________
Taking any medication that may affect your
Diabetes Y/N _____________________________
exercise program Y/N _____________________
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