USVI Public Records

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BUCS Fitness Club HEALTH SURVEY FORM Please read the questions carefully and answer each one honestly by circling YES or NO. • If you answer YES to one or more of the questions: Talk to your doctor by phone or in person BEFORE you start becoming much more physically active. You may be able to do any activity you want as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those that are safe for you. Talk to your doctor about the kinds of activities you wish to participate in and follow his/her advice. We require a note clearing you for exercise if you circle YES to any question. • If you answer NO to all the questions: If you answer NO honestly to all the Health Form questions, you can be reasonably sure that you can start becoming much more physically active, begin slowly and build up gradually. This is the safest and easiest way to go. • Delay becoming more active: If you are not feeling well because of a temporary illness such as a cold or fever, wait until you feel better. If you are pregnant, talk to your doctor before becoming more active. • Please note: If your health changes so that you would then answer YES to any of the questions, tell your health professional. Ask whether you should change your physical activity plan. Any YES answers or any changes in health that result in answering YES to any of the following will require a doctor’s release. YES NO Has your doctor ever said that you have a heart condition, high blood pressure or heart disease? YES NO Has your doctor ever said that you should only do physical activity recommended by a doctor? YES NO Do you feel pain in your chest when you do physical activity? YES NO Do you lose your balance because of dizziness or do you ever lose consciousness? YES NO Do you have a bone or joint problem that could be made worse by a change in your physical activity? (for example: Arthritis, Rotator Cuff problem, joint replacement). YES NO Is your doctor presently prescribing drugs (I.e.: water pills) for blood pressure or a heart condition? YES NO Do you know of any other reason why you should not do physical activity? YES NO Do you have any other pre-existing illnesses, diseases or conditions that may prevent you from participating in physical activity? I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction. I have read and fully understand the contents of this agreement. Print Name: ___________________________________ Date (expires in one year): ______________ Signature of User: ___________________________________________________________________ Fitness Club Personnel Signature:______________________________________________________