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Pre Assessment Questionnaire

OFFICE USE ONLY Card Number Date:

IPQ Form


Sport@Kenton NE3 3RU

Staff Sign

Surname: Title: Male: Female: Full Address: Tel Home: Mobile: Emergency Contact:

Forenames: DOB: Post Code: Tel Work: E-mail: Name: Number:

1. Has your Doctor ever said that you have a heart condition and that you should only do physical activity recommended by a Doctor? Yes No 2. Do you ever feel pain in your chest when you do physical exercise? Yes No 3. Have you ever had chest pain when you were not doing physical exercise? Yes No 4. Do you ever feel faint or have dizziness? Yes No 5. Do you have a joint problem that could be made worse by exercise? Yes No 6. Have you ever been told you have high blood pressure? Yes No
7. Are you currently taking any medication of which the instructor / teacher should be made aware of? If so what?


No Notes:

8. Are you pregnant or have you had a baby in the last 6 months? Yes No 9. Do you have breathing problems? Yes No 10. Do you have any skin infections or open wounds? Yes No 11. Is there any other reason why you should not participate in physical activity? If so what? Yes No Notes:

Yes to one or more question from 1 -11: Talk to your Doctor before you start taking physical
exercise and before you complete your fitness induction. You may well be able to do any activity you want, as long as you start slowly and build up gradually. Or you may need to restrict your activities to those which are safe for you. Talk to your Doctor about the kinds of activities you wish to participate in and follow their advice.

Please read and complete section overleaf

No to all questions: You can be reasonably sure that you can start taking exercise. Begin slowly
and build up gradually. However, postpone your induction if you have a temporary illness. If you think you may be pregnant, talk to your Doctor before you start an exercise program.

Referred to Doctor

Staff Sign

Equal opportunity monitoring

Kenton School wants to ensure that our leisure provision meet the needs of all our clients and the following information would help us to achieve this. Do you consider yourself to be: (tick one box only)

Doctors' agreement to participation in exercise Yes No Doctor's Signature: Date:

Irish White : British Black : Black British African Mixed White & Black Caribbean White & Black African Asian: Asian British Indian Bangladeshi Pakistani Other ethnic group: (please specify)

Caribbean White Asian Chinese

Do you consider yourself to have a long standing illness, disability or infirmity which limits your daily or work in any way? Yes (see below) No If so, please tick disability type: Visual Impairment Learning Disability

Hearing Impairment Multiple Impairment

Physical Impairment Heath / Other Impairment

Induction Status - Gym equipment may vary between gyms you have used before.
I have had an induction I have not had an induction and would like to book one I have been offered an induction but decline this offer at my own risk. Staff Sign___________________ Data Protection Act 1998
Sport@Kenton follows the guidelines set out below. Kenton School will use the information you provide for the purpose of Leisure Centre administration. We would like to be able to send you information on our services. Our partner organizations would also like to send you information about their services. If you are happy for us to do this please tick the appropriate box.

Sport@Kenton Yes No Partner organisations Yes No If you have any questions concerning date protection you can contact: Kenton School HR Officer on 0191 2142200 or by e-mail at Formal Declaration I declare to the best of my knowledge I know of no reason why I should not participate in exercise. I take part in any form of exercise entirely at my own risk and waiver any legal recourse for damage to myself or property arising from my participation. Signed Office Use Initial Fee: Linked Membership: Name Dated Monthly Fee: Membership No:
SO / Card / Cash

Card / Cash / Cheque


Kenton School Fitness Suite Induction Form

Name: Safe and Appropriate use of the Fitness Suite Sign in at reception before training commences Dress Code - Appropriate footwear / appropriate clothing Bags - Must not be taken into the fitness suite Drinks - No glass bottles in the fitness suite Age - Must be 16 yrs (unless taking part in a school based activity supervised) Hygiene - Must wipe down machines after use Report any faults in the book on the fitness suite desk or to staff if available If unsure about any exercise/training equipment ask staff for assistance If feeling unwell or suspect others are unwell contact staff immediately Any inappropriate behaviour to be reported to staff Centre Layout Changing rooms/toilets/lockers/fire exits - alarms/ water fountain Staff location during operation times Cardiovascular Operation Suggested kit for all CV Equipment including footwear Safety clip/emergency stop button treadmill Quick Start function/program selection Heart rate telemetry Resistance Operation Function image on each piece of kit Seat adjustors/limb length adjustors Weight selection/incremental increase device Speed of movement Only use kit for what it was designed for (no modifications/addition of own kit) Free Weight Zone Dumbbell range up to 20kg No dropping of the weights Return weights to racks provided Awareness of fellow users close by Cable Action (DPC) Membership No: Date Joined

Variety of attachments Carabineer System Awareness for fellow users close by

Customer Signature: Staff Signature:

Date: Date:

All users must sign a copy of this form along with a copy of IPQ Form. Both forms to be kept on site for reference at any time.