Questionnaire

All clients have to answer all the questions before starting sessions

Full Name

Mobile Phone Number

Work Phone Number

Date of birth

Occupation

Doctor

Telephone

Osteopath/Physiotherapist

Telephone

Other medical consultant

Telephone

Next of Kin. Who should we call in case of an emergency?

Have you been cleared for exercise by your doctor?

Yes

Have you ever suffered high blood pressure or heart problems? Yes/No If ‘Yes’ please provide full details

Have you ever suffered digestive complaints? (ulcers, colitis etc) Yes/No If ‘Yes’ please provide full details

Have you ever suffered with respiratory problems? Yes/No If ‘Yes’ please provide full details

Have you ever had any bone or stress fractures? Yes/No If ‘Yes’ please provide full details

Have you ever had any muscle, ligament or tendon problems? Yes/No If ‘Yes’ please provide full details

Have you ever had any ankle sprains or strains? Yes/No If ‘Yes’ please provide full details

Have you ever had any knee injuries? Yes/No If ‘Yes’ please provide full details

Have you suffered any back or neck pain? Yes/No If ‘Yes’ please provide full details

Have you had any surgery? Yes/No If ‘Yes’ please provide full details

Have you ever been involved in a car accident? Yes/No If ‘Yes’ please provide full details

Is there anything in your medical history or current circumstances not dealt with in the above questions that I should know about? Yes/No If ‘Yes’ or you are unsure, then in the interest of your own health and safety, please disclose any such matter now

I accept the terms and conditions and realise I must take responsibility of my own body, stop exercising and if I need to and tell the teacher of anything I experience during the class or between classes that may be exercise related

I also understand that the teacher may offer professional advice relating to my ability to exercise and that s/he may consider it unprofessional to continue to teach me if I do not wish to follow such advice

Your Signature

Thanks for answering! I will get back to you.