MindSTONES Enquiry Form

The Gallagher Stadium,
James Whatman Way,Maidstone,
Kent ME14 1LQ

info@stonesct.org.uk

Registered Charity No. 1184274

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code

Phone Number*

Area CodePhone Number

E-mail*

example@example.com

Date of birth

Date

Any existing medical conditions

Please provide details of any health conditions

What are your main reasons for starting this programme?

Rows	Yes	No
Has your doctor ever said you have a heart condition that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had a chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (for example back, knee, or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing medication for your blood pressure or a heart condition?
Do you know of any other reason why you should not take part in physical activity?

If you have answered 'Yes' to the 'Any other reason' question above please provide more details:

I.C.E (In case of an emergency contact name and telephone number)

If you have answered 'Yes' to one or more questions above you should consult with your doctor to clarify it is safe for you to become physically active at this current time and in your current state of health.

If you have answered 'No' to one or more questions it is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.
A fitness appraisal can help determine your ability levels.

I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable levelof exercise, and my participation involves a risk of injury

By signing this form you are confirming that you are consenting to MindSTONES a programme of The Stones Community Trust, holding your details for use in case of a medical emergency.

You can withdraw your consent at any time by contacting the Trust.

Signature*

Date*

Date

Name*

Having answered YES to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise.

Name

Signature

Date

MindSTONES Programme