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.

Participants Details:*

First NameLast Name

What is your / their current age?*

When is your / their Birthday?*

Contact Number:*

For minors, please use the parent / guardians details

Email Address*

For minors, please use the parent / guardians details

Do you / they have High Blood Pressure?*

YesNo

Do you / they have Low Blood Pressure?*

YesNo

Do you / they have, or have suffered from, a Heart Condition?*

YesNo

Is there a history of Coronary Heart Disease in your / their Family?*

YesNo

Have you / they ever suffered from shortness of breath during rest or light exercise?*

YesNo

Do you / they have Asthma?*

YesNo

Do you / they currently Smoke?*

YesNo

Do you / they ever feel feint, become disorientated, dizzy, or fall unconscious?*

YesNo

Do you / they have any conditions or injuries relating to your bones or joints (i.e. Arthritis) that could be affected by exercise?*

YesNo

Do you / they have any allergies or conditions that may be affected during physical exercise and the close quarter proximity of others?*

YesNo

Have you / they been diagnosed or suspected of having any neurodivergent conditions (i.e. ADHD, Autism)?*

YesNo

Do you suffer from any other type of injury, illness, or condition that may affect you during any of these sessions (i.e. Diabetes)?*

YesNo

If you have answered yes to any of the above, please provide details:*

(Please place N/A if this does not apply to you)

Parent / Guardian or Next of Kin details:*

First NameLast Name

Relationship to Participant:*

Contact Number:*

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*

Date

Participant or Parent / Guardian Signature:*