INFORMED CONSENT

Note: Please fill all necessary details in the document, and submit the same to the Gymnasium Counselor before
commencing usage of the Gym equipment’s as authorized user. All this information will be kept
confidential. Employees not filling these will be treated as unauthorized user.

I, __________________________________________________________, Employee Id ________________

Understand that before beginning my exercise program, I should consult with a Physician.

It is agreed that using Gym facilities shall be undertaken by an employee at his/her liable risk, and Amdocs
Development Centre India Pvt. Ltd. or Gymnasium Management shall not be liable for any accident or mishap arising
out of this.

It is also agreed that I am responsible for any damages caused by me to the facilities and equipment of the gym, I
also agree to abide by the rules & regulations of the Amdocs Gym and will extend my co-operation to the Gym
Management staff.

I have read all the details of this form and comply with the same.

Employee Id:

Name:

Signature:
 Gym Rules
1. Amdocs Gym is open for all Amdocs India employees.
2. This is a voluntary activity and all employees are taking part on its own decision & risk. Company or
Gymnasium Management will not be held responsible for any untoward incidences and no claim should arise
out of this activity.
3. It is expected that normal acceptable social/ behavioral norms will be adhered to at all times, be with
colleagues or with Gym management staff.
4. Employee’s code of conduct is to be adhered to at all times.
5. In the interest of your own health, please follow instructions from the gym management staff.
6. The management shall not be responsible for the loss of belongings of the members, and will not entertain any
claims in this respect. Members are advised not to keep valuables in the changing room.
7. Medical records to be shared with Counselor/ Instructor in case required.
8. Music/TV noise should not be disturbing to office working. In case there is any such request by employees
working in office, it would be attended to.
9. Regular work shoes are not allowed inside Gym. Members should use the separate exercise shoes only in the
Gymnasium.
10. Proper Gymnasium attires needs to be worn.
11. Employees to get their own toiletries & towels (e.g. Towel & bath towel)
12. Company reserves right to change / modify Gymnasium rules at any point. This will be displayed on the
Gymnasium Notice board whenever there is change.

Timings:
Gymnasium along with Instructor will be kept open only during specified timings as below:
a. Morning : 0600 to 0900 hrs with Instructor
b. Evening : 1800 to 2200 hrs with Instructor

I will be doing the exercise at my own risk and I hereby indemnify Amdocs Gym and its management from any
loss/damage occurring to me while doing the exercise in the Fitness Club.

I have read the house rules of the Amdocs Gym and I agree to abide by the same.

Employee id:

Name:

Signature:
 HEALTH HISTORY QUESTIONNAIRE
Regular physical activity is safe for most people. However, some should check with their doctor before they start an
exercise program. To help us determine if you should consult with your doctor before starting to exercise with
Amdocs Gym, please read the following questions carefully and answer each one honestly.

Personal Information:

Home Address (local):

Telephone Home: Ext. No. (Office): Mobile No:

In case of emergency, please notify:

Name: Relationship:

Contact No.

Height: Weight:

Gender: Birth Date: Age:

General Information:

 What are your specific goals at Amdocs Gym (indicate all that apply)

Increase strength & endurance Improve flexibility

Improved cardiovascular fitness Improve muscle tone
Exercise regularly Increase muscle mass
Sports conditioning Injury rehabilitation
Reduce body fat Increase weights
Others

 What are your specific health goals at Amdocs Gym (indicate all that apply)

Reduce stress Improve nutritional habits

Control blood pressure Control cholesterol
Exercise regularly Achieve balance in life
Improve productivity Reduce back pain
Feel better overall Increase my health awareness
Others (please be specific)
Medical Information

Tick if applicable (  or ×)
Family history of heart Severe Headaches Surgery in the recent
problems past
High blood pressure Fainting spells Chronic illness
Stroke history Seizures or Convulsions Bone joint problem
Heart Disease Dizziness Male over 44 years
Irregular heart beat Numbness or tingling Female over 54 years
High Cholesterol level Depression Pregnancy
High Triglyceride level Chronic Bronchitis Anemia
Chest pain while engaging in Shortness of breath Allergies
physical activity Lung problems Diabetes
Chest pain when you are not Asthma Use of diuretics
doing any physical activity Cigarette smoking habit Alcoholism/ Substance
abuse

Musculoskeletal Information

Please describe any past or current musculoskeletal conditions you have incurred such as muscle pulls, sprains,
fractures, surgery, back pain or general discomfort, etc.

Nutritional Information

Are you on any specific food/nutritional plan at this time? Yes/ No

If yes, please list:

Do you take dietary supplements? Yes/ No

If yes, please list:

Do you exercise any frequent weight fluctuations? Yes/ No

Any specific reasons behind joining exercise activity? Yes/ No

Health Treatment Information

Name of Physician: Contact Phone:

Are you under the care of a physician or other health care professional for any reason: Yes/No

If yes, list reason and medication:

Please list any other problems (Gents/ Ladies):

I have read all the details, understood, completed this questionnaire and comply with the same. Any questions that
I had were answered to my full satisfaction.

Name: Date:

Signature:

Staff Use only (to be filled by Gym management)

Cleared to exercise: Not cleared to exercise:

Reason:

Staff signature:
Date:

Resting heart rate:

Blood pressure:

Systolic (mm Hg):

Diastolic (mm Hg):

Staff Name & signature:

Employee signature:
 FITNESS ADVISOR SHEET

 Do you start exercise program but then find yourself unable to stick to them?
Yes / No

If yes why___________________________________________________

 How much are you willing to devote to an exercise program?

_________________ minutes/day ____________ days/week

 Are you currently involved in regular exercise? Yes / No

If yes, please specify the type of exercise (s)______________________________________

___________________ Minutes/day _____________ days/week

 How long have you been exercising regularly?

___________________ Months ______________ Years

 Do you have any medical problem that restricts you from doing a fitness program
Yes / No

If yes, please specify the type of problem _________________________________________

 What type of exercise interests you?

Walking Jogging Aerobics

Cycling Dance Weight Training

Stationary biking Rowing

Stretching Yoga

Flexibility Functional Training /Plyometric

 MEASUREMENT CARD

Employee id:
Photograph

Name:

Date

Neck

Shoulder

Chest

Upper
Abdomen

Waist

Lower Abdomen

Biceps

Forearms

Wrist

Hips

Thigh

Calf

Ankle

Height

Weight