Health Questionnaire

  • Health Questionnaire

  • This form is to be completed in full for each individual that wishes to participate in any of our classes or private sessions (including as EmpoweringPT). Please make sure to complete this form at least a day before you or your child wishes to take part. For yours and everyone else's safety, you will not be allowed to participate until the instructor has been able to check the details. Be aware that should this not be completed ahead of time and the instructor be unable to read the report (due to running the class), you may not be able to participate, but will still be charged.

  • When is your / their Birthday?*
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  • Do you / they have High Blood Pressure?*
  • Do you / they have Low Blood Pressure?*
  • Do you / they have, or have suffered from, a Heart Condition?*
  • Is there a history of Coronary Heart Disease in your / their Family?*
  • Have you / they ever suffered from shortness of breath during rest or light exercise?*
  • Do you / they have Asthma?*
  • Do you / they currently Smoke?*
  • Do you / they ever feel feint, become disorientated, dizzy, or fall unconscious?*
  • Do you / they have any conditions or injuries relating to your bones or joints (i.e. Arthritis) that could be affected by exercise?*
  • Do you / they have any allergies or conditions that may be affected during physical exercise and the close quarter proximity of others?*
  • Have you / they been diagnosed or suspected of having any neurodivergent conditions (i.e. ADHD, Autism)?*
  • Do you suffer from any other type of injury, illness, or condition that may affect you during any of these sessions (i.e. Diabetes)?*

  • Disclaimer:

    By clicking submit, you are confirming that all of the details you have provided are correct at the time of submission and agree that you will complete another form should any of these details change. You are also giving permission for Empowerment Reading Martial Art School / EmpoweringPT to take pictures and film during any of our sessions in order to promote our services, as well as store and use any data provided in this form to be able to contact you, and add you to our Whatsapp groups and newsletters.

  • Todays Date*
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  • Should be Empty: