Name

First

Last

Email

Phone Number

Date of Birth (DD/MM/YYYY)

Emergency Contact (name)

Emergency Contact (number)

Has your doctor advised you not to participate in exercise?

Yes
No

Do you feel pain in your chest at rest or when you do physical activity?

Yes
No

Do you lose your balance because of dizziness or do you ever black out?

Yes
No

Do you get short of breath at rest or doing light activity?

Yes
No

Do you have a heart condition? (e.g., angina, palpitations, atrial fibrillation or have you ever had a heart attack?)

Yes
No

Have you ever had a stroke or a mini stroke?

Yes
No

Are you suffering from Long Covid?

Yes
No

Are the any other health issues I should be made aware of – please note overleaf or by email.

Do you have any difficulties with your breathing such as COPD, emphysema, chronic bronchitis, asthma or any other lung condition?

Yes
No

Do you have diabetes, high blood pressure or epilepsy?

Yes
No

If yes, please indicate which.

details health aware

Do you have any bone, joint, muscular or neurological conditions which affect your ability to exercise such as osteoporosis, back pain, multiple sclerosis, Parkinson’s or arthritis? Include any joint replacements.

Yes
No

Have you had any operations in the last 3 months?

Yes
No

Have you had a fall in the last 12 months?

Yes
No

Do you have (or have you had) cancer?

Yes
No

Do you take any medication that may be required in an emergency?

Yes
No

Do you have any allergies including latex?

Yes
No

Can you walk for 20 minutes?

Yes
No

If so how many times a week do you do this?

If you answered YES to any of the above please ask your GP/ health care professional before participating. If you answer ‘yes’ to any of the questions, please provide details on the back.

Please provide details of any other needs you have that the instructor should be aware of such as walking aids, hearing or sight difficulties, physical or learning disabilities.

I have read, understood and completed this questionnaire honestly and agree to keep my instructor informed of any changes. I understand that I participate at my own risk. Please sign to indicate your consent to share this information with us.

I agree

Signature (type full name)

Date (DD/MM/YYYY)

We may sometimes take photos or film sessions for use in social media and advertising. If you DO NOT consent to being filmed please ensure the instructor is made aware of this.

I consent to being filmed/photographed
I DO NOT consent to being filmed/photographed