Screening - Felda

FELDA HEALTH, FITNESS AND SPA SCREENING FORM

The information contained in this form is totally confidential and is only used to plan a safe and effective training program for you.

Name*

Mr/Mrs/Miss First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Date Of Birth*

Email*

Medical Contacts

Emergency Contact Name*

Emergency Contact Number*

Doctor Name*

Doctor Number*

Medical Conditions

Please answer the following questions by circling the appropriate response: Do you suffer/have ever suffered from any of the following conditions?

Heart Disease / Chest Pain when exercising*

High or low blood pressure*

History of heart disease or stroke in your family (before 55 yrs)*

Asthma or Lung Problems*

Diabetes*

Thyroid Condition*

Epilepsy*

Hernia*

Are you currently on any type of medication*

Muscle Joint or Back Pain*

Are you / have you been pregnant in the last 6 months*

Have you had any surgery in the last 6 months*

Have you been advised by a doctor not to exercise*

Do you have any other conditions which may limit your exercise*

Please provide details*

Do you smoke*

If so - how many per day

Do you exercise regularly*

If so - please provide details

Have you had a cholesterol test*

If so - please provide details

More Information

If you answer “Yes” to any of the above please explain your condition

Customer Agreement*

I intend to use facilities/ take part in the exercise program, assessment/ class offered by Felda Health, Fitness and Spa. I am aware that as with all types of exercise there is an inherent risk of heart attack, death, light headedness, fainting, cramps, muscle or joint injury etc. I understand the risks and know that I am free to withdraw from the exercise or modify my activity levels at any time. I assume full responsibility during and after my participation to use or apply at my own risk any portion of the information or instruction I receive. I understand that Felda Health, Fitness and Spa accepts no responsibility whatsoever for any injuries or death during or after participation in the program, assessments/exercise classes. I have read, understood and agree the contents of this informed consent agreement in its entirety.

YES
NO

Membership Agreement - Details

Membership Term*

Payment Method*

How did you pay

Terms Of Membership*

I hereby agree that I will use the facilities of Felda Health, Fitness and Spa at my own risk and that Felda have no liability whatsoever, whether in tort or in contract, for any loss, injury or damage whatsoever sustained by me. I accept full responsibility for my use of any and all facilities, appliances, privilege or service and hold harmless Felda Health, Fitness and Spa, its employees, representatives, agents or lessors, from any and all loss, claim injury, damage or liability sustained or incurred by me or my property, howsoever caused.

YES
NO

Marketing and GDPR

How did you hear about Felda?*

Website, Social Media, Email, Print, Radio, Word Or Mouth, etc

Marketing Consent*

Email Marketing - Promotions, Newsletters
Text Marketing - Renewal Reminders, Membership Status, Promotions & Motivations
No Marketing - Opt back in at any time

Felda Privacy Policy - https://felda.ie/privacy-policy*

I have read and understood this policy

YES
NO

Official Use Only

Name

This field is for validation purposes and should be left unchanged.

Thank for for joining up to Felda

Please complete the new members screening form below :-

New Member Screening/GDPR Form