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pre exercise health
Prior to taking part in any of my classes please fill out the following medical form
First Name
Email Address
Has your Doctor ever indicated that you have a heart condition?
No
Yes
Have you ever been made aware that your cholesterol was high?
No
Yes
Do you experience dizziness or fainting?
No
Yes
Are you bothered with severe chest pains during physical exertion?
No
Yes
Are you diabetic?
No
Yes
Are you taking any medication or prescribed drugs?
No
Yes
Last Name
Date of Birth
Has you Doctor ever said that you suffer from high blood pressure?
No
Yes
Are you bothered with severe chest pains during physical exertion?
No
Yes
Do you have any bone, joint or muscular problems?
No
Yes
Are you Pregnant or have been within the last 6 months?
No
Yes
Do you suffer from arthritis?
No
Yes
Do you suffer from...
Epilepsy
Asthma
Further info ie; prescribed medication, position of injuries or arthritis, recent surgery etc
I declare that the info I’ve provided is accurate & complete
Initials
Today's Date
Submit
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