Health Questionnaire

Home Health Questionnaire

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 - 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 - 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.

Membership Form

Please make sure that you have also filled out our membership form!

Membership Form

Purity Gym is an independent boutique Gym, established in 2015 and has been bringing a top-notch fitness facility to the people of Telford and its surrounding areas since then.