HEALTH FORM

Yoga & Pilates with Carly

First name

Last name

Email

Phone

Date Of Birth

Day

Month

Year

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes

No

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

Yes

No

In the past month, have you had chest pain while you were not doing physical activity?

Yes

No

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

Yes

No

Do you have a bone or joint problem that could be made worse by physical activity?

Yes

No

Is your doctor currently prescribing drugs for your blood pressure or heart condition?

Yes

No

Are you pregnant or recently had a baby?

Yes

No

Have you had any recent injuries or operations?

Yes

No

Do you know of any other reason why you should not do physical activity?

Yes

No

If you have answered YES to ANY of the above questions please provide more details and information below

Is there anything else I should know about?

I hereby state that I have read, understood and answered honestly all questions on this form. I also state that I wish to participate in activities of which may include aerobic exercise, resistance training and stretching. I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in exercise and practicing at my own free will, I agree that I do so at my own risk.

I confirm, that if I have answered yes to any of the above questions I have consulted my medical professional / GP / DR and they give permission for me to attend exercise classes

The data on this form will be stored in strict confidence. Carly Circuitt will not be held responsible for any loss / damages to property / belongings while participating in classes. I accept the terms and conditions stated on this form. Please Note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional.

Your contact details will be kept strictly confidential. Please tick this box if you do not wish for your details to be stored on a computer

This is a Please tick to give permission to be added to our mailing list for information on our classes. .

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HEALTH FORM

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