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Personal Informationrole2Date Date Format: DD dash MM dash YYYY First Name*Last Name*Date of Birth Contact InformationAddress Street Address Address Line 2 City County Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Email* AccountUsername*Password* Enter Password Confirm Password Medical questionnaire [PAR-Q]Person to contact in case of emergency*Emergency Contact Number* Questions 1. Has your doctor ever said that you have had a heart condition and that you should only do physical activity recommended by a doctor?*YesNoPlease explain2. Do you feel pain in your chest when doing physical activity?*YesNoPlease explain3. In the past month, have you had chest pain when you were doing physical activity?*YesNoPlease explain4. Do you lose your balance because of dizziness or do you ever lose consciousness?*YesNoPlease explain5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?*YesNoPlease explain6. Is your doctor currently prescribing drugs ( for example, water pills ) for your blood pressure or heart condition?*YesNoPlease explain7. Do you know of any reason why you should not do physical activity?*YesNoPlease ExplainAgreement* I have read and understood the above information. If there are any changes in my circumstances above, I will inform the studio. Talk with your doctor BEFORE you start becoming much more physically active or BEFORE you undergo a fitness programme. Talk with your doctor about the Lift questionnaire and to which questions you answered YES. - 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 which are safe for you. - Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. - See reverse if you decide not to consult your doctor. If you answered NO honestly to all the 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. - We recommend you have a group orientation or personal training session to determine your basic fitness. Delay becoming much more active: - If you are feeling unwell because of a temporary illness such as a cold or fever- wait until you feel better. - If you are or may be pregnant – talk to your doctor before you start becoming more active. Please note: If your health changes so that you then answer YES to any of the above questions, before exercising tell an instructor. Ask whether you should change your physical activity plans. Waiver Claim: Although this questionnaire is designed to assist Lift when advising on individual exercise needs, members are reminded that Lift cannot be held responsible for the health of individual members and that it is the responsibility of all members to consult their doctor prior to commencing any exercise programme.