Health screening questionnaire

  • Health Screening Questionnaire

  • Personal Information
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  • Please provide the following details for in the event of an emergency:
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  • Lifestyle Information
  • Is your occupation desk based?*

  • Medical Information
  • Are you taking any regular medication which may affect you during the session?*
  • Have you any illnesses or disabilities?*
  • Please indicate if you have been diagnosed with any of the following conditions:
  • Do you have any injuries or joint problems?*
  • Have you had surgery within the past 12 months?*
  • Are you or have you been pregnant within the past 12 months?*
  • Are you aware of any reason that you should not participate in physical activity without medical supervision?*

  • 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 become pregnant or experience any new or unusual symptoms during the course of my class(es).

     

    Please note, we cannot be aware of your inherent medical issues and as such cannot be held liable for any unforeseen medical problems or physical injury arising from our classes. You should always consult your physician or other healthcare provider before starting an exercise programme.

     

    I understand that there is a risk of injury associated with participating in Yoga & Pilates classes. I hereby assume full responsibility for any and all injuries, losses and damages that I incur while attending, exercising or participating in the classes. I hereby waive all claims against Zoe or Becki individually or otherwise, for any and all injuries, claims or damages that I might incur.

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