Health Form - MEMBERS ONLY

Personal Details

First name*

Last name*

Birthday*

Day

Month

Year

Phone*

Email*

Health & Wellbeing

Do you have any medical conditions we should know about?*

Yes

No

Please provide details:

Are you currently taking any medication?*

Yes

No

Please provide details:

Have you had any recent surgery or hospital treatment?*

Yes

No

Please provide details:

Do you have any injuries, pain or physical limitations?*

Yes

No

Please provide details:

Has a healthcare professional ever advised you to avoid or modify exercise?*

Yes

No

Please provide details:

Have you exercised regularly before?*

Yes

No

Is there anything about your health, medical history or physical wellbeing that we should be aware of?*

Yes

No

Please provide details:

Emergency contact

Name*

Relationship *

Phone*

Consent

I confirm that the information I have provided is accurate and complete. I understand that The GPC Clubhouse will use this information to help provide services and experiences that are appropriate and safe for me. I agree to inform The GPC Clubhouse of any relevant changes to my health or wellbeing.