Health Questionnaire

Please complete the following prior to exercise.

    Your First Name

    Your Surname

    Your Address

    Your Post Code

    Your Email

    Your Telephone

    Your Date of Birth

    Your Emergency Contact Details (name and number)

    Please indicate YES or NO to the following questions:

    Has your doctor ever said that you have a heart condition and recommended any medically supervised activity?

    Do you have chest pains brought on by physical activity?

    Have you ever developed chest pains in the last month?

    Do you have a joint or bone problem that could be aggravated by exercise?

    Has a doctor ever recommended medication for your blood pressure or a heart condition?

    Has a doctor or other health professional ever told you not to participate in physical activity?

    Have you had Covid-19 and suffered from symptoms?

    Are you currently suffering from any signs or symptoms of Long-Covid, ie. chronic fatigue?

    I declare, to the best of my knowledge that I know of no reason why I should not participate in a Roefield exercise programme.
    I acknowledge that there are risks inherent to physical exercise, and I agree to abide by the verbal instructions given to me by the fitness instructor and will observe any written notices regarding safety whilst using the fitness suite and its equipment.
    I agree to notify the fitness instructor should there be any changes to my health which may affect my ability to perform physical activity.
    I can refrain from all or any part of the physical activity should I wish to do so.
    I will not hold the fitness instructor or Roefield Leisure responsible for any injuries sustained in an outdoor, uncontrollable environment. Risk assessments may not always be undertaken prior to activities and your own personal judgement must be relied upon for your own safety.
    Please select a response to accept/deny these terms and conditions.

    By completing this form I agree to the terms and conditions of use at Roefield Leisure and understand that the centre may contact me via email, SMS, telephone or post for the purpose of delivering the services to me. The information collected on this form (including but not limited to my personal data) will be used by Roefield Leisure and third parties approved by Roefield Leisure to enable the delivery of services.

    Please tick the box if you would like to receive information on Roefield Leisure events, activities and promotions.

    By ticking this box I agree that Roefield Leisure and third parties approved by Roefield Leisure and acting on its behalf may contact me via email, SMS or post, using the personal data I have provided on this form, with information on events, activities and promotions.

    If you wish to unsubscribe from future email communication regarding Roefield Leisure events, activities and promotions please send an email to and add unsubscribe to the subject line.