Soulfull Yoga And Fitness Registration Form

Client Details:

Full Name

First NameLast Name

Date of birth

Date

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: 00000-000000.

E-mail

example@example.com

How did you hear about us?

Please Specify

What services are you interested in?

What are your main reasons for starting with Soulfull Yoga and Fitness?

Do you have any history or have any of the following medical conditions? Please check all that apply

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you ever have pain, pressure, heaviness or tightness in the chest area?

Have you ever had severe dizzy spells or episodes of fainting?

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Have you had any recent operations (in the last two years)?

Are you currently taking any oral medication, tablets, pills etc

Do you have any old injuries that still trouble you? Or any otherMedical conditions not covered above that might be adversely affected by exercise?

Are you receiving treatment for any diagnosed medical condition? Or any therapy such as a chiropractor or Osteopath?

Are you /could you be, pregnant, or have you given birth in the last six weeks?

If you answered yes to the previous questions, please provide more details here :

Emergency Contact:

First NameLast name

Phone Number

Please enter a valid phone number.Format: 00000-000000.

I have read, understood and accurately completed this questionnaire. I confirm the above information is correct. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.

I confirm the above information is correct. I understand that it is my responsibility to: -

• Check with my Doctor if I have any difficulties or concerns about my ability to participate

• Advise the my Trainer/Teacher of any change in my medical information

• Follow the advice given by my doctor and/or Trainer

Please note

If you answered YES to one or more questions, talk with your doctor by phone or in person BEFORE you start becoming much more physically active to clarify that it is safe for you to become physically active at this current time and in your current state of health or BEFORE you have a fitness appraisal. You may be able to do any activity you want – as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those that are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can: Start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.

Take part in a fitness appraisal and consulation – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live more actively.

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