Print this form to get started.

Answer all of the questions by circling 'yes' or 'no' for each item. Give any special details in the space provided. Sign this form and show it to your physician for approval before starting your personal exercise program.

Have you ever had any of the following medical conditions?

If yes, please provide details / dates in the space provided: 

Asthma or Bronchitis     YES  NO  ____________________________________________
Arthritis                YES  NO  ____________________________________________
Diabetes                 YES  NO  ____________________________________________
High BP (> 140 / 90)     YES  NO  ____________________________________________
Low BP (< 100 / 60)      YES  NO  ____________________________________________
High cholesterol         YES  NO  ____________________________________________ 
Dizziness / Fainting     YES  NO  ____________________________________________
Epilepsy                 YES  NO  ____________________________________________
Glandular Fever          YES  NO  ____________________________________________
Gout                     YES  NO  ____________________________________________
Hernia                   YES  NO  ____________________________________________
Lung Disease             YES  NO  ____________________________________________
Stroke                   YES  NO  ____________________________________________
Heart Conditions         YES  NO  ____________________________________________
Chest pain               YES  NO  ____________________________________________
Shortness of breath      YES  NO  ____________________________________________
Swollen/painful joints   YES  NO  ____________________________________________
Regular muscle pain      YES  NO  ____________________________________________
Stomach ulcer            YES  NO  ____________________________________________ 
Do you drink alcohol?    YES  NO  ____________________________________________
Do you smoke?            YES  NO  ____________________________________________
Are you on medication?   YES  NO  ____________________________________________

Have any of your close relatives suffered from - 
or ever been diagnosed with heart or artery disease?       YES  NO
  
__________________________________________________________________________

Are you pregnant or have you given birth in the 
last 12 weeks?                                             YES  NO

__________________________________________________________________________

Do you have any injuries which might limit your 
participation in an exercise program?                      YES  NO

__________________________________________________________________________

I am aware that my involvement in this fitness program is completely 
voluntary. I consent to participate in the fitness program and I 
withdraw my right to make any claim of any kind against David G. Keir 
(Sports Insight Australia Pty Ltd), Scigolf, its directors and employees 
for any injury, illness or adverse change in my medical condition or 
state of health arising directly or indirectly from this fitness program. 
I represent and warrant to David G. Keir and Scigolf that I have 
furnished details of any medical condition I have (or may have had) and
 of all recent medical treatment received by me. I have read the foregoing 
and I understand it. Any questions which may have occurred to me have been 
answered by my physician to my satisfaction.

Signature: _____________________________   Date: ____________________

Physician Approval:_____________________   Date: ____________________

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