Pre-Activity Induction Health Questionnaire Web Pre-Activity Gym Induction Health Questionnaire Please note: This form should ONLY be completed if it has been requested in advance of a Gym induction . If you have any difficulties completing this form then please talk to a member of staff. Personal Information Name * Name First First Last Last Preferred Name Date of Birth * Current Age * Gender * Please select From the followingMaleFemaleNon-BinaryOther Contact Telephone Number Email Address Emergency Contact Details Name * Name First First Last Last Relation to you Contact Telephone Number Can this Person be contacted at any time? * Yes No If No Give Secondary Emergency Contact If No Give Secondary Emergency Contact First First Last Last Relation to you Phone GP Information Name of Doctor * Surgery Name and Address Surgery Name and Address Surgery Name and Address Surgery Name and Address Town Town County County Post Code Post Code Surgery Phone Number In the event of health conditions and/or emergency, do you consent for Bridge to contact your GP for further information relating to said condition/emergency? * Yes No Please Note that you must complete and send this form in to the gym instructor prior to using the Gym. If you are human, leave this field blank. Next
