Yogomotiv - Health Screening Form

New Client Information & Health Screening Form

By entering my details below, I explicitly consent to my medical questionnaire (including any data in it about my physical and mental health) being processed by Yogomotiv Limited for the purpose of providing safe and effective exercise classes and to ensure my safety during in:person or online classes.
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In an Emergency, please provide details of someone we can contact*

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Physical Activity Readiness Questionnaire (Par-Q)
Have you participated in any type of exercise before? If so, what type?
If you are planning to take part in physical activity, please start by answering the questions below. The questionnaire has been designed to identify for whom it would be recommended to seek medical advice before starting. If you have any concerns about your health, please see your doctor before participating.

Please read the following questions carefully and answer each one honestly: Tick 'YES' or 'NO' as appropriate*

Rows	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel fain in your chest when you do physical activity?
Have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing medication for blood pressure or any heart condition?
Do you know of any other reason why you should not do physical activity?
Do you suffer from any of the following:
Diabetes
High Blood Pressure
Low Blood Pressure
Osteoporosis
Epilepsy
Asthma / Breathing Problems
Arthritis
Cardiac Problems
Stress Incontinence

If you have answered YES to any of the questions above, please provide more information here:
YES to one or more questions:

You should consult with your doctor to confirm that it is safe for you to become physically active at this time and in your current state of health.

NO to all questions:

It is reasonably safe for you to participate in physical activity, gradually building up from yoru current ability level.
Medication : Are you currently taking any medication?*

YesNo
Please include all medications, names, doses etc below
Treatment : In the last 12months, have you had any treatment from a Doctor or had any medical procedures?*

YesNo
If YES, please provide details below
Medical Clearance : Do you need medical clearance to exercise?*

YesNo
If YES, please provide details of any specific advice they have given in relation to exercise (Please note: a note may be required from your health care professional)
Informed Consent : Exercise programmes are designed to improve cardiovascular (heart and lungs), fitness, muscle tone and strength, endurance and flexibility. When participating in activities / exercises, you are likely to experience different levels of intensity over varying lengths of time. As a result, you may experience quicker breathing patterns, an increase in heart rate and become hot very easily. The activities / exercises you participate in will be explained to you and demonstrated but you are advised to ask questions if you are not clear about anything. Any exercise carries with it an element of risk such as muscle pulls, joint strains, aches, pains and general discomfort in parts of the body. Please inform the instructor prior to the session if there is any reason why you should not participate in an activity; for example an illness or injury, which might be aggravated by exercise. If, at any time, you feel undue pain or excessive discomfort, stop the activity immediately and inform the instructor. I have read and understood the conditions and risks of participation and I consent to voluntarily taking part in the activities required. I understand that I am free to withdraw my consent and to withdraw from the activities at any time, without negative consequences.*

Please check box to confirm that you have read and understood
Release of Liability: By signing below, I confirm I have completed this questionnaire and read and understood that physical activity involves a risk of injury. Any questions I had were answered to my full satisfaction. By signing below, I understand that sessions taken with Yogomotiv Limited may be physically strenuous and I voluntarily participate in them with the full knowledge that this is a risk of personal injury or death.*

Please check box to confirm that you have read and understood
Privacy Notice : By signing below, you explicitly consent to us processing the personal data you have included in this form in accordance with our Privacy Policy that is set out on our website (https://yogomotiv.com/terms-and-conditions/#privacy-policy ) for the purposes of us providing the services and as otherwise set out in our Privacy Policy. We may from time to time send you details of our goods or services that we feel may interest you, including promotional offers (such as money off vouchers or buy five sessions get one free or free sessions)] by email or post. You may opt out of receiving such communications at any time. Please tick below to let us know how we can contact you :

YES - by EMAILNO - by EMAILYES - by TEXTNO - by TEXT
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New Client Information & Health Screening Form

Physical Activity Readiness Questionnaire (Par-Q)