Participation Form Medical & Health Questionnaire To be completed once you have confirmed your place on the bootcamp Gender: MaleFemale Date of birth: Contact information Medical history You should consult your doctor prior to any form of exercise program or physical activity, ESPECIALLY IF YOU ARE NOT USED TO ANY EXERCISE Has your doctor ever advised you not to exercise?(*) YesNo Do you have asthma? (*) YesNo Do you have diabetes? (*) YesNo Do you have Emphysema?(*) YesNo Have you ever had pneumonia?(*) YesNo Do you have or ever had heart trouble?(*) YesNo Have you ever had a stroke?(*) YesNo Do you ever have problems breathing? (*) YesNo Do you have high cholesterol? (*) YesNo Have you ever had a hysterectomy? (*) YesNo Are you pregnant?(*) YesNo Have you recently given birth?(*) YesNo Do you have high/low blood pressure?(*) YesNo Do you ever feel faint during exercise?(*) YesNo Do you take any medication? (*) YesNo If you have answered yes to any of the questions above please give details Do you have Epilepsy? (*) YesNo Do you have or had Glandular Fever?(*) YesNo Do you have or had a Hernia?(*) YesNo Do you have or had cancer?(*) YesNo Do you have any Liver or Kidney infection?(*) YesNo Do you have any infectious diseases?(*) YesNo Have you been hospitalized in the last 12 months?(*) YesNo Have you suffered any broken bones in the last 12 months?(*) YesNo If you have answered yes to any of the questions above please give details Do you smoke?(*) YesNo Have you ever smoked?(*) YesNo Do you drink? (*) YesNo Do you take any recreational drugs? YesNo If so what are they? Do you or have you had arthritis?(*) YesNo Do you suffer from gout?(*) YesNo Do you suffer from any allergies?(*) YesNo Do you have any existing back problems?(*) YesNo Have you ever torn a muscle?(*) YesNo Have you ever had an embolism?(*) YesNo Have you ever suffered brain injury?(*) YesNo If you have answered yes to any of the questions above please give details Current exercise/activity Do you exercise currently?(*) YesNo If no exercise when was the last time you participated in any exercise?(*) Never2 Years +1 Year +3-12 Months>3 Months How active are you currently? Not activeModerately activeExtremely active What is the intensity of exercise?(*) HighModerateLow Eating habits How would you describe your diet? BadGoodFairly goodExcellent How many times a day do you eat? OneTwoThreeFourMore than four Do you snack throughout the day? YesNo PERSONAL GOALS In order to submit the form you will need to offer specific consent DISCLAIMER: Although the benefits of these sessions are significant, there is always an element of risk involved with any physical activity. These sessions are designed in such a way to minimise the risk of injury. However, you are taking part at your own risk; gobootcamp or anyone associated with gobootcamp will not be held responsible for any damages, injuries or otherwise that may occur as a result of taking part in boot camp sessions. If at any time during a session you feel discomfort or pain, you should notify your instructor immediately. You are strongly invited to ask your instructor any questions that you may have during the rest intervals throughout your sessions. Your participation in these sessions are entirely voluntary and you may opt out at any given time if you so wish. You will be expected to have purchased your own personal insurance prior to attending gobootcamp as you would for a holiday