BASIXGym Health Waiver

To register to our gym please fill out the following medical form

Do you have a bone or joint problem such as arthritis, which has been aggravated by exercise or might be made worse with exercise?
To your knowledge, do you have high blood pressure?
Do you have Diabetes mellitus or any other metabolic disorder?
Has your doctor ever said that you have raised cholesterol (serum level above 6.2mmol/L)?
Do you have or ever suffered a heart condition?
Have you ever felt pain in your chest when you do physical exercise?
Is your doctor currently prescribing you drugs or medication?
Have you ever suffered from shortness of breath at rest or with mild exercise?
Is there any history of Coronary Heart Disease within your family?
Do you ever feel feint, have spells of dizziness or have ever lost consciousness?
Do you currently drink more than the average amount of alcohol per week (21units for men and 14 units for women (1 unit = ½ pint of beer/cider/larger or 1small glass of wine))
Do you NOT currently exercise regularly (at least 3 times per week) and/or work in a job that is physically demanding.
Are you, or is there any possibility that you might be pregnant?
Do you know of any other reason why you should not participate in a programme of physical activity?
I hereby give my consent for my picture to be taken and displayed on both the gym’s website, www.basixgym.com and related social media pages

If you answered YES to one or more questions:

If you have not already done so, consult with your doctor by telephone or in person before increasing your physical activity and/ or taking a fitness appraisal. Inform your doctor of the questions that you answered ‘yes’ to on the PAR-Q or present your PAR-Q copy. After medical evaluation, seek advice from your doctor as to your suitability for:

1. Unrestricted physical activity starting off easily and progressing gradually, and …

2. Restricted or supervised activity to meet your specific needs, at least on an initial basis.

If you answered NO to all questions:

If you answered the PAR-Q honestly and accurately, you have reasonable assurance of your present suitability for:

1. A graduated exercise programme, 2. A fitness appraisal.

ADDITION TO CURRENT PAR-Q AND ASSUMPTION OF RISK AND RELEASE OF LIABILITY

Please understand that despite all the precautions that you, other members, and/or BASIX GYM LIMITED may take, we cannot guarantee your health or safety, and you may still be exposed to COVID-19, including through interactions with other individuals who have COVID-19.  By executing this release and gaining access to the facility, you, on behalf of yourself, your heirs, beneficiaries, representatives, successors and assigns: (1) voluntarily assume all risks associated with any exposure to COVID-19, including, but not limited to suffering any type of medical condition, illness and, potentially, death; and (2) knowingly and voluntarily waive, release, covenant not to sue, forever discharge, indemnify, and hold harmless BASIX GYM LIMITED, its parents and subsidiaries and their respective officers, directors, employees, contractors, agents, representatives, successors and assigns (“Released Parties”) from any and all liability, damages, losses, suits, demands, causes of action to the fullest extent permitted by the laws of this state, or any other claims of any nature whatsoever, arising out of or relating in any way to your use of the facility and your potential exposure to COVID-19.

Your Signature

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