Clubbercise with Emma Ando
Health Questionnaire
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number
Emergency contact
First Name
Last Name
Emergency contact number
Have you ever suffered with epilepsy?
Yes
No
Are you pregnant?
Yes
No
Have you ever suffered with heart conditions?
Yes
No
Are you presently taking any medication?
Yes
No
Do you suffer with chest pains?
Yes
No
Do you suffer with feeling faint or dizziness?
Yes
No
Have you ever suffered with high/low blood pressure?
Yes
No
Have you ever suffered with high/low cholesterol?
Yes
No
Have you ever had asthma, chronic bronchitis or any other chest alignments?
Yes
No
Do you suffer from servere back pains or any other orthopedic problem?
Yes
No
Do you suffer from severe head aches or migraines?
Yes
No
Are you recovering from recent illness, injury or operations?
Yes
No
Have you any medical condition we should be aware of?
Yes
No
Is there any history of heart disease in your immediate family (before 55)
Yes
No
If you answered yes to any of the above questions, please give details below.
I agree to my personal contact information to be used to send me important class updates. IMPORTANT if you don't agree it will not be possible for me to let you know about any changes to classes, cancellations etc.
Agree
Disagree
Data protection. This information will be stored in line with the General Data Protection Regulations (GDPR) and the privacy policy of Emma Anderton. Clubbercise Ltd will not receive this data and will not be responsible for protecting this data.
Accept
Health Commitment statement. Your health is your responsibility. I am dedicated to helping you take every opportunity to enjoy my classes that I offer and I have carefully considered what we can reasonably expect from each other. My Commitment to you: I will respect your personal decision and allow you to make your decisions about what exercise you can carry out. However I ask you not to exercise beyond what you consider to be your own abilities. I will make every reasonable effort to make sure that my equipment and facilities are in a safe condition for you to enjoy.
Accept
Your Commitment to me: You should not exercise beyond your abilities. If you know or are concerned that you have a medical condition which might interfere with you exercising safely, before you take part in any classes you should get advise from relevant medical professionals and follow that advise. You should not carry out activities which you have been told are not suitable for you. You should let me know immediately if you feel ill when taking part in any of my classes. If you have a disability you must follow any reasonable instructions to allow you to exercise safely
Agree
I have been informed that if I answer YES to any of the questions above I should seek medical advise/approval before commencing class. If I wish to continue without such advise I do so entirely at my own risk. I confirm I have read, fully understood and answered each question honestly. I understand that the nature of the class and confirm that I am in appropriate physical and mental condition to participate. If at any time I have any questions, feel unsafe or unwell I will immediately inform the instructor and discontinue further participation on the class. I understand that neither the instructor or clubbercise Ltd can be held responsible for any injuries or ill health of any kind arising from participation within the class.
Agree
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: