Health Screening

Health Screening

Confidential
This has been designed to ensure that you begin your Dance Coaching Session quickly and safely. Please complete as honestly and accurately as possible.
Name
Tel No

Area CodePhone Number
D.O.B

MonthDayYear
Date
Occupation
Have you ever, or are you currently suffering from any of the following?

DiabetesEpilepsyBack ProblemsArthritisHigh/Low blood pressureAsthmaStressThrombosisDizziness
If yes to any of the above please give details
Do you have, or have you ever had a heart problem or suffer from chest pains?
If YES, please give more details
Is there a family history for coronary heart disease below the age of 60?
If YES, please give more details
Have you had any operations in the last 6 month?
If YES, please give more details
Do you currently take any medication?
If YES, please give more details
Have you had any recent serious illnesses?
If YES, please give more details
Do you have any injuries, bone or joint problems?
If YES, please give more details
Do you smoke?
If YES, please give more details
Do you exercise regularly?
If YES, please give more details
Ladies only – Are you, or is there any possibility that you are pregnant?
If YES, please give more details
Any other additional information:
Should be Empty: