INSTA RUN CLUB HEALTH QUESTIONNAIRE

Name*

First NameLast Name

Instagram Name*

Address

Street Address

Street Address Line 2

CityCounty

Post Code

DOB

Date

Email*

example@example.com

Phone Number

Area CodePhone Number

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?*

YESNO

Do you feel any pain in your chest when you do physical activity?*

YESNO

Do you lose your balance or have dizziness or do you ever lose consciousness?*

YESNO

Do you have a bone or joint problem that could be made worse by a change in your physical activity?*

YESNO

Have you ever been told by your doctor that you have high blood pressure?*

YESNO

Is your doctor currently prescribing drugs for your blood pressure or heart condition?*

YESNO

Do you suffer from Diabetes or Epilepsy?*

YESNO

Do you suffer from Asthma?*

YESNO

IF YOU HAVE ANSWERED YES TO ANY OF THE QUESTIONS ABOVE THEN PLEASE SPEAK TO YOUR GP/DOCTOR BEFORE PARTICIPATING IN ANY EXERCISE PROGRAMMES. IF IN DOUBT PLEASE SEEK YOUR GP/DOCTORS ADVICE

INFACT BEFORE THE START OF ANY PROGRAMME, WE ENCOURAGE ALL PARTICIPATES TO UNDER GO A FULL MEDICAL WITH THEIR GP/DOCTOR.

What are your current pbs?

If I choose to take part in training programmes and sessions delivered or suggested by Real Runners I acknowledge that:

1) I am aware and understand the potential risks and dangers associated with participation in physical activity and any equipment that may be used in Real Runners sessions and I am voluntarily participating in these activities with knowledge of the risks and dangers involved. I hereby agree and accept full responsibility for any injuries or death that may occur during a session

2) I know of no reason why I should not participating in any of the activities at Real Runners. If I should not participate, I will not participate. I hereby declare myself free of any condition, illness or injury that may affect my participation. I agree to inform Real Runners if this changes at any point or if anything declared within my Heath Questionnaire changes which may affect my ability to participate in Real Runners sessions.

3) I agree to abide by any safety notices given to me during classes lr sessions and am aware that I have the opportunity to ask questions about any of the activities, use of equipment or other session related issues. If I choose to listen to advice or notices given to me or if I choose to ignore them, I do so voluntarily and accept liability for any resulting injuries or damage.

4) I do hereby accept all responsibility or liability for any injuries or damages resulting from my participating in any activities that I take part in at Real Runners.

5) Direct Debit Cancellation Notice | 1 month

6) Please adhere to governement guidelines regarding COVID-19 and social distancing.

By signing below, I have read, understood and completed this questionnaire and agree to be bound by its condition.

PRINT NAME*

Signature*

Once submitted you will be direcred to payment page and then link to insta page

Where did you hear/told you about our Run Club?

Instagram Run Club Health Questionnaire