Client Health Screening Questionnaire

Client Health Screening Questionnaire
PLEASE ENSURE YOU COMPLETE ALL OF THE FOLLOWING INFORMATION
1. Are you taking any regular medication which may affect you during the session?

YesNo
If YES, please provide details
2. Have you any illnesses or disabilities?

YesNo
If YES, please provide details
3. Do you have any injuries or joint problems?

YesNo
If YES, please provide details
4. Have you had surgery within the past 12 months?

YesNo
If YES, please provide details
5. Are you or have you been pregnant in the past 6 months?

YesNo
6. Please indicate below if you have been diagnosed with any of the following conditions:

Epilepsy or seizuresHeart conditionRheumatoid arthritisAsthmaDiabetesHigh/low blood pressureMetal implantPacemakerBlood disorder
7. Are you aware of any reasons that you should not participate in physical activity without medical supervision?

YesNo
If YES, please provide details
I have read, fully understood and completed this questionnaire. The answers that I have given are accurate to the best of my knowledge. I understand that it is my responsibility to inform the instructor if I experience any new or unusual symptoms during the course of my class(es).
Name
Email
example@example.com
Date
Should be Empty: