Health Questionnaire for FABilates PopUp

HEALTH PAR Q

Your answers on this questionnaire will make sure Mairi Taylor can tailor any exercises to your needs, and determine your suitability for working out with us on line. Please tick the relevant box next to each question, then fill in your details at the bottom of the form. All information will be treated with the strictest of confidence.
Name*

First NameLast Name
Date of birth*

DayMonthYear
Date
Gender*

FemaleMaleNon- binary
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityCounty

Postal Code
Name of Emergency Contact*

First NameLast Name
Address of Emergency Contact*

Street Address

Street Address Line 2

CityCounty

Postal Code
Phone Number of Emergency Contact*

Area CodePhone Number
Please indicate whether you have been diagnosed with any of the following diseases or symptoms

Do you have a heart condition and/or been recommended for medically supervisedactivity?Do you have any pelvic floor dysfunction ?Have you developed chest pain in the last 12 months?Do you suffer from breathlessness after slight exertion?Do you suffer from dizziness or fainting?Do you currently have high blood pressure that you know of? If yes, please indicate the reading in the notes boxAre you over 65 and unaccustomed to regular physical activity?Do you have Diabetes Mellitus?Do you have a joint problem that could be aggravated by physical activity? If so, please please state in the notes boxDo you have muscle soreness or pain when moving? If yes, please indicate where in the notes boxIs there any other reason why you should not partake in regular physical activity? If yes, please indicated in the notes box
If you have answered ‘yes’ to any of the above questions, please inform me as your GP may need to be contacted prior to commencing a fitness regime.
Provide further information if any
Please indicate whether any of the following apply to you

Is there a family history of heart disease in your immediate family under the ageof 65?Have you ever had a cholesterol test? If yes,please indicate the results in the notes boxDo you currently smoke?Do you exercise regularly?Are you currently pregnant or is there any possibility that you might be?Do you suffer from epilepsy?Are you currently taking any medication? If yes, please indicate in the notes boxHave you had a baby in the last 12 weeks? If yes please indicate what type of birth you had in the notes box
Provide further information if any
If your health changes so that you would answer YES to any of the above questions, please inform me or your GP immediately. Ask whether you should change your physical activity or exercise plan. Delay becoming more active if you feel unwell because of a temporary illness such as cold or flu – wait until you are better.

CLIENT RELEASE STATEMENT (please read carefully before signing)

I willingly participate in the practical exercises classes on line at my own risk.

I have no physical restrictions, disabilities or any predisposition to sickness or injury that may be aggravated or adversely affected as a result of my participation.

I take full responsibility for any injury, loss or damage to my person or property that may arise directly or indirectly from my participation in the on line exercises, and will ensure that the area I use at home is clear and free of trip and slip hazards.

I will not seek to penalise, prosecute or claim compensation from the instructor for any injury, loss or damage, whilst working out at home.

I understand I should seek medical advice from my GP if I am in any doubt about my physical ability to take part in Fitness Classes with Mairi Taylor. I acknowledge I am undertaking this activity entirely at my own risk and that Mairi Taylor shall not be liable in any way for any injury or loss that might occur as a result of my participation, from working out at home.

I have made my instructor Mairi Taylor aware of any changes to my Health questionnaire that may affect my ability to participate in her PopUP FABilates Classes.

I understand that photographs may be taken during classes for promotional purposes, and that I can request not to be included in any photographs.

I understand that the data on this form will be stored safely and used solely by the company according to GDPR regulations and for my benefit for as long as I continue to take Mairi Taylor's Classes.

Your data will be stored for 7 years after your last class.

I understand that I have full access to view what data is held by the company about me, and that I can ask for this data to be corrected or deleted at any time.

This information is protected by the General Data Protection Regulation 2016
Please note that we will store your personal details securely for future orders and will never share them with third parties for marketing purposes. We may, from time to time, contact you with details of suitable news of offers, classes or useful information. Please indicate your preferred method of contact:

EmailPhonePost
I have read, understood and completed this questionnaire. All questions have been answered to the best of my knowledge. I recognise that the instructor Mairi Taylor is not able to provide me with medical advice with regard to my medical fitness and that the above information is used only as a guideline to the limitations of my ability to exercise on line.*

Yes
Date completed*

DayMonthYear
Date
Client signature*

Clear
Mairi Taylor 48 Ribble Drive Barrow upon Soar Loughborough LE12 8LJ
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