Health questionnaire Form

Angela's Aerobics Client information
Full name*

First NameLast Name
Address

Street Address

Street Address Line 2

City

Post Code
E-mail
If you are on WhatsApp are you happy to join a group specific to your class?

YesNo
Best Contact Number*

Area CodePhone Number
Emergency contact*

First NameLast Name
Phone number*

Area CodePhone Number
Birth Date*

MonthDayYear
Sex
Are you pregnant?*
How did you hear about me?

FriendAdvertisementSocial MediaOther
Which of my services interests you more?

Pilates50's+ZumbaDigital Classes1 to 1
OCCUPATION & LIFESTYLE
What do you do for a living?
What do you do in the day to stay active?
How much time do you spend in a seated position?
How many hours sleep do you get?
How much fluid do you drink per day?
Do you have any swollen, stiff or painful joints?
Do you have tension or soreness in a specific area?
Medical History
Have you ever suffered from?*

AsthmaHigh or Low Blood PressureEpilepsyDiabetesDizziness or FaintingFrequent ColdsHeart DiseaseShortness of breathHigh CholesterolHeadaches or MigrainesPain on calf when walkingDoes it go away when you continue walking?Arthritis or aches and pains in the jointsDifficulty keeping your balanceNone
If yes to any of the above please give more details*
Have any of your first degree relatives experienced the following conditions?

Heart AttackStrokeHigh CholesterolHigh Blood PressureCongenital Heart DiseaseDiabetesNONE
Have you had surgery in the last 2yrs?*

YesNo
If yes give details*
Do you smoke?
Do you suffer from back pain?*

YesNo
If yes please give details*
Do you have any injuries?*
If yes please give details*
Is there anything else I should know about? If yes please give details
Is there anything that could affect your ability to exercise? If yes please give details
Do you take any...?*

MedicationsSupplementsNone
If yes please list*
How would you rate your current physical fitness. (1 - poor 10 - Athlete
Please read the following T & C's
1.) LATE ARRIVALS

Each session shall be 45-60mins. Sessions will not be extended due to the lateness of the client or due to interruptions caused by the client. If you arrive 5mins after a group session had started you will unfortunately not be able to attend.

2.) No refunds or transfer of classes given.3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

3.) Cancellations for 1:2:1 sessions should be made at least 24 hours in advance of a scheduled session. Sessions cancelled less than 24 hours in advance will be charged in full to the client.

4.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.
I agree to the above T&C's*
Client informations - Liability waiver
Clients undertake all training at their own risk. You should always discuss any new exercise regime and participation in our training sessions with your medical professional. If you decide to participate in these sessions without medical approval, you will assume all responsibility for your participation in these activities and use of any equipment in the activities.
Should you experience any chest pain, dizziness or shortness of breath at any time while exercising you should stop immediately and consider seeking medical help.
As this is an online class participants are responsible for their own safety and health and exercises shown are for demonstration purposes only.
Angela’s Aerobics does not take any responsibility for injuries or illness caused to participants during these online classes.
Please make sure you have enough space to manoeuvre safely during the exercises removing any obstructions/trip hazards and stay hydrated.
Please sign below as read and agreed.
Signature*

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Angela's Aerobics Client information

OCCUPATION & LIFESTYLE

Medical History

Please read the following T & C's

Client informations - Liability waiver