Contact

Name

Date Of Birth

Telephone No

Doctor's Name

Doctor's Telephone No

Emergancy Contact Name

Emergancy Telephone No

If you answer “YES” to any of the first 3 questions (below) please consult your doctor before taking part in the above-mentioned class.

Has your doctor ever indicated that you have heart trouble
yesno

Do you frequently suffer from pains in your heart or chest? or have chest pains brought on by physical activity?
yesno

Has a doctor ever said your blood pressure was too high?
yesno

Are you presently taking any medication?
yesno

Have you been diagnosed with osteoporosis?
yesno

Have you been diagnosed with osteoporosis?
yesno

Do you have any other bone or joint problems that could be aggravated by taking part in this class?
yesno

Do you become breathless after walking up a flight of stairs?
yesno

Is there a reason not mentioned here why you should not follow an activity program?
yesno

Are there any other medical conditions that the instructor should be made aware of?
yesno