Health screening questionnaire

Health Screening Questionnaire
Personal Information
Full Name*

First NameLast Name
Mobile Phone Number*

Area CodePhone Number
Email address*
Please provide the following details for in the event of an emergency:
Emergency contact number *

Area CodePhone Number
Emergency contact name*

First NameLast Name
Lifestyle Information
Please provide details of any regular exercise that you currently undertake:
Is your occupation desk based?*

YesNo
Medical Information
Are you taking any regular medication which may affect you during the session?*

YesNo
If yes, please provide details:
Have you any illnesses or disabilities?*

YesNo
If yes, please provide details:
Please indicate if you have been diagnosed with any of the following conditions:

AsthmaMetal ImplantA heart conditionDiabetesA PacemakerRheumatoid ArthritisEpilepsy / SeizuresHigh blood pressureLow blood pressureA blood disorder
Do you have any injuries or joint problems?*

YesNo
If yes, please provide details:
Have you had surgery within the past 12 months?*

YesNo
If yes, please provide details:
Are you or have you been pregnant within the past 12 months?*

YesNo
Are you aware of any reason 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 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.
Name*
Date*
Signature*

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