PYSICAL ACTIVITY READINESS QUESTIONNAIR

PLEASE FILL IN THE FOLLOWING FORM TO HELP US UNDERSTAND YOUR HEALTH CONDITION.

First Name

Email Address

Last Name

Date of Birth

Have you been hospitalized in the last 12 months? *

No

Yes

Are you currently suffering from a medical condition, illness, or injury? *

No

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

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JACKOS GYM

COLLOP GATE FARM

MANCHESTER ROAD

OL10 2PX

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REFUND POLICY

LIABILITY WAIVER

COVID-19 INFORMATION

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