Purity Gym - Changing Bodies, Building Confidence
1A King Street, Wellington, Telford, TF3 1AH
01952 252770
info@puritygym.co.uk
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Health Questionnaire
Client Form 3a
For all health & fitness services carried out by staff and representatives of Purity Gym Ltd.
Please fill the below out and amember of the team will get back to you.
Part A - Health
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Check those which apply to you
Smoker
High Blood Pressure
Heart Murmur
Exercise Regularly
High Cholesterol
Angina
Family History of Heart Disease
Type II Diabetes
Allergies
Part B- Medical History
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Have you ever diagnosed with or managed any of the below?
Asthma
Stroke
Osteoporosis
Any other joint/bone condition
Back Problem
Had a Recent Operation
Currently Pregnant
Osteo - Arthritis
Other Muscular Condition
Loss of Sleep
Emphasema
Type I Diabetes
Rheumatoid Arthritis
Multiple Sclerosis
Have you experienced any symptoms of COVID-19
I declare that I have answered all the questions in this health appraisal to the best of my knowledge and that this is a true reflection of my current state of health. I accept that Purity Gym Ltd may ask for further advice from my GP or other recognised health professional before I can access their services.
I consent for Purity Gym Ltd to take and use my image in any advertising media
I am aware that any treatment or physical activity that I may take part in, may present a heightened risk of injury, ill health or death. I understand that I reserve the right to refuse to partake in any exercise or treatment method that I do not feel happy or comfortable with. While all attempts will be made to minimise these risks, I do not hold Purity Gym Ltd responsible for any harm that may come to me should choose I decide to participate in such task.
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