St Finians GAA Swords

* Full name

* Email (for receipt)

* Mobile number

* FITNESS INFORMATION: Are you currently exercising?

* Type of exercise? (or enter none)

* Frequency of exercise?

* What do you wish to achieve in the St Finians GAA Club gym? Please list your goals:

* MEDICAL INFORMATION: Are you currently seeing a medical practitioner for any injuries or illness?

* Do you have any current medical conditions?

* If Yes to the previous question. Please specify, (or just enter 'None')

* In the past 6-12 months, have you undergone any surgical procedures? Please specify.

* Do you have a family history of heart disease?

* Have you ever suffered from a heart condition?

* Have you ever suffered from any of the following? Please specify, (or just enter 'None')Chest PainChest TightnessShortness of breath from exertionHeartburnNone

* Do you have high blood cholesterol?

* Do you have any type of diabetes?

* Do you have a pacemaker? Please comment:

* Do you take any prescribed medication? If Yes, What type and why?

* Do you take any nutritional supplements? If yes, what type and why?

* Is there a family history of prostate cancer, breast cancer or colon cancer? Please Specify:

* Do you have or have you ever had any of the following conditions: (Please Tick) or just tick 'None'High blood pressureStrokeAsthmaGoutHeart murmurDiabetesEpilepsyChrone’s DiseaseRecent weight gain/lossGlandular FeverDizzinessLung diseaseSinus ProblemsStomach UlcerArthritisDrug or Alcohol ProblemsDepressionThyroid ProblemsNone

* Any other symptoms or conditions that concern you?

* Do you smoke?

If you answered, Yes to the previous question (Do you smoke?). How many per day?

* Are you pregnant now or have you recently been pregnant?

* Do you have any muscular injuries or pain? Please specify

* Do you have any joint injuries?

* If you answered, Yes to the previous question. What area(s)? Please specify, (or just enter 'None')BackneckKneesShouldersAnklesElbowsHipsOtherNone

* If you answered Other to the previous question, please specify. Otherwise write 'None'

* Do you suffer from arthritis?

* Do you suffer from osteoporosis?

On a scale of 1-10 (1 = no stress, 10= overwhelming stress), how would you rate your current stress levels? (Please Circle) at work

On a scale of 1-10 (1 = no stress, 10= overwhelming stress), how would you rate your current stress levels? (Please Circle) at personal

* Do you have any reason why you should not exercise in a program?

Founded 1983

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