Pre-class Questionnaire
Personal Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date
*
-
Month
-
Day
Year
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Health Questionnaire
All information on this form will be treated confidentially. If you would like to discuss any of your answers please speak to your Turn’dUp Fitness Instructor.
Has your doctor ever said that you have a heart condition or hypertension and/or recommended supervised physical activity?
Please Select
Yes
No
Do you feel pain in your chest when you do physical activity?
Please Select
Yes
No
In the past month, have you had chest pain when you were resting?
Please Select
Yes
No
Do you lose balance because of dizziness or do you ever lose consciousness?
Please Select
Yes
No
Do you have a bone or joint problem (for example, OA, RA, OP) that could be made worse by a change in your physical activity?
Please Select
Yes
No
Is your doctor currently prescribing any medication or treatments?
Please Select
Yes
No
Do you have any of the following? If yes please give details:
Asthma
Diabetes
Epilepsy
CHD
Mental Health problems
If you have answered yes to the above please provide details below.
Are you, or have you recently been, pregnant?
Please Select
Yes, I am pregnant
Yes, I have recently been pregnant
No
Do you know of any other reason why you should not do physical activity?
Please Select
Yes
No
Do you have any additional learning or learning support needs, eg Dyslexia?
Please Select
Yes
No
Please note: answering ‘yes’ to a question may not mean exclusion from the class but adaptations may be necessary, so please give full and honest answers to all questions. If in doubt please speak to your instructor.
Signature
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