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Health Screening Form
Please fill out the following health declaration form in order to participate in our classes either online or in halls.
First Name
Last Name
Email
Date of Birth
Best Contact No
Emergency Contact Number
Address
Town
County
Post Code
Sex
*
Female
Male
Are you active on a daily basis?
*
Yes
No
Have you ever suffered from?
Asthma or shortness of breath
Headaches or Migraine
Persistent back ache
Cartilage trouble
High or Low blood pressure
Epilepsy
Diabetes
Dizziness or fainting
High cholesterol
Hernia
Angina
Slipped/bulging disc/prolapse
Are you pregnant or had a baby in the last 6 months?
None
If you have ticked any of the above, please add any additional information below.
Have you had surgery in the last 2 years?
Yes
No
If, YES, please give details...
Do you have any injuries?
Yes
No
If, YES, please give details of injury...
Do you take any?
Medications
Supplements
None
If, YES, please list
How you would you rate your current fitness level? 1 being poor to 10 being very fit
*
1
2
3
4
5
6
7
8
9
10
The above health responses given are reflective of my current status. I agree to inform Love Pilates and my instructor, if there are any changes in my health status due to injury, illness or otherwise. I will consult with my doctor and not partake in the class until I have been advised by my doctor, that it is safe for me to do so. I acknowledge that there are inherent risks in taking physical exercise and that I know of no medical reason why I should not undertake a Pilates/Fitness exercise programme. I also agree to comply with any verbal instructions from the instructor regarding health and safety whilst doing the class at home/or face to face.
I give my consent for Love Pilates to hold my contact details and health screening data and use them to send me class information/newsletters when appropriate.
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