PRIVACY STATEMENT
The information on this form is collected for the primary purpose of processing your membership. Other purposes of collection include creation of electronic records, attending to administrative matters and corresponding with you. By completing all the questions on this form, GV Functional Fitness is able to process your membership. You have the right to access personal information that GV Functional Fitness holds about you, subject to any exceptions in relevant legislation.

If you wish to seek access to your personal information or enquire about the handling of your personal information, please ask your Personal Trainer. Your information will NEVER be shared with any third party without your prior consent.

Regular communication is an important aspect to our service.
 email sms telephone

GV Functional Fitness always recommends that before you undertake any physical activity, you should first undergo a complete physical examination from a registered medical practitioner, to ensure that you are fit and able to commence your exercise program. You should advise your medical practitioner that the exercise program includes weight lifting, circuit training, aerobic and anaerobic exercise over prolonged periods of time.

2. MEDICAL HISTORY

Please choose YES OR NO for the following questions

Has your Doctor ever said you have bone, joint or muscle problems such as Arthritis that has been aggravated or
might be made worse by exercise?

Has your Doctor ever said your blood pressure is too high? (eg over 140/95)

Have you ever had a heart attack, coronary revascularisation surgery or a stroke?

Has your doctor ever told you that you have heart trouble or vascular disease?

Has your doctor ever told you that you have a heart murmur?

Do you ever suffer from pains in your chest, especially with exercise?

Do you ever get pains in your calves, buttocks or at the back of your legs during exercise, which are not due to
soreness or stiffness?

Do you ever feel faint or have spells of severe dizziness, particularly with exercise?

Do you experience swelling or accumulation of fluid about the ankles?

Do you ever get the feeling that your heart is suddenly beating faster, racing or skipping beats, either at rest or
during exercise?

Do you have chronic obstructive pulmonary disease, interstitial lung disease, or cystic fibrosis?

Have you ever had an attack of shortness of breath that developed when you were not doing anything
strenuous, at any time in the last 12 months?

Have you ever had an attack of shortness of breath that developed after you stopped exercising, at any time
in the last 12 months?

Have you ever been woken at night by an attack of shortness of breath, at any time in the last 12 months?

Do you have diabetes [IDDM or NIDDM]? If so, do you have trouble controlling your diabetes?

Do you have any ulcerated wounds or cuts on your feet that do not seem to heal?

Do you have any liver, kidney or thyroid disorders?

Do you experience unusual fatigue or shortness of breath with usual activities?

Do you have Asthma or any allergies? Please describe:

Do you have Epilepsy or similar condition?

Are you pregnant? If so, how many weeks?

Is there any other physical reason or medical condition, or are you taking any medication(s) which could prevent
you from undertaking an exercise program, or that you are concerned about? Please describe:

NOTES:
Some of these conditions might include a history of blood clotting, osteoporosis, bone fractures or serious
musculoskeletal disorders, or if they have recently lost a large amount of body mass without trying to. Other types
of conditions might include psychiatric disorders, later-stage pregnancy or those with a history of health problems
during pregnancy. Those people taking medication(s) for medical conditions listed may also need medical clearance.