Welcome to the Glanbia Health Questionnaire
Name: *

Address: *

Telephone *

Occupation *

Date of Birth *

Age *

Current illness/disease? *

If yes please state illness/disease

Current, recurring or past injury? *

If yes please state injury

Are you taking any Medication? *

If yes please state medication

Back/Knee/Joint problems?  *

If yes please state the issue

Pregnant *

Have you ever suffered from the following problems?

Heart Condition *

High Blood pressure *

Low blood pressure *

Epilepsy *

Diabetes *

Schizophrenia *

Faint/dizziness *

High Cholesterol *

Angina *


Do you currently exercise? If yes please state briefly what you do:

Informed concent *

In completing the form I hereby consent to take part in any induction/class/fitness programmes at my own risk.   If I have any known health problems I will discuss them with my instructor. If the instructor offers any reason for not joining in this exercise programme I will adhere to those recommendations.   I understand that the risks of undertaking physical activity and exercise may include disorders of heartbeats, abnormal blood pressure response, and, very rarely, a heart attack or death.   I further understand that selection and supervision of exercise is a matter of professional judgement.   I understand that I can withdraw my consent or discontinue participation in any aspect of the fitness programmes at any time without penalty or prejudice toward me.   I have read the statement above and have had all of my questions answered to my satisfaction.

Please note that if you do not accept you will not be eligible to use the gym facility.
Glanbia Waterside Gym Courtesies Please read the following carefully and if in agreement please click I agree at the end.   *

·         The Gym is for employees only.
·         Each individual must use their own Fob to access and exit the gym. Fob access is given once induction process is complete.
·         Proper gym attire must be worn at all times (T shirt, Track bottoms, shorts and runners)
·         Participants must provide their own towels. Towel to be carried at all times while in the gym.
·         Users must wipe down equipment with sanitary wipes provided after use.
·         When a Gym user leaves the gym he /she should normally take their gym bag with them. On no account can gym bags be left           in the gym over-night.
·         Food & Drink are not allowed in the gym (except drinks in leak proof containers) and water from fountain.
·         Please re-rack weights and put equipment back in its correct position.
·         Weights are not allowed to be dropped on the floor-please lower slowly to the ground.
·         Showers and locker areas should be left spotlessly clean. (as you would wish to find them)
·         Talking on mobile phones is not permitted in the gym area.
·         For your information a Defibulator is kept on the 1st floor landing of Waterside. There is also a panic button to use in    
          emergency located near the FOB unit at the gym exit door.
·         Temporary access can be given upon signing the consent form available from the receptionist/PA.
·         In case of any dispute management decision is final!  

Note  The provision of the gym (and any relevant charges) is a discretionary benefit and the Company will review this annually. I further agree to follow the rules and courtesies above or as may be amended from time to time.  If you do not agree you will not be eligible to use the gym.
Thank you for filling out this health questionnaire. 

You will receive an invite to join the Glanbia Gym online portal within 24 hours where you will be able to book your gym induction
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