health questionnaire Name * First Name Last Name Date of birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number Email * Occupation * Emergency Contact Name * Emergency Contact Number * Medical History If you are answering YES to any of the questions please check with your health professional that you can undertake physical activity and provide further detail where necessary to Flex and Flow 1. Do you have any health conditions - eg osteoporosis, epilepsy, diabetes, recent surgery,cardiac problems etc - if yes please provide details 2. Are there any chances that you could be pregnant? * Yes No 3. Do you have a high blood pressure (hypertension?) * Yes No 4. Do you have any conditions that may give you pain? If yes, please provide details * 5. Do you have any injuries or disabilities? * Yes No If yes and you have a health professional e.g Physio, have they suggested anything that you shouldn't do? 6. Do you have any respiratory conditions eg asthma? yes/no * Yes No 7. Are you taking medication? * Yes No What are you hoping to achieve from attending the class? Release It is your responsibility to consult your GP before attending classes, and seek medical consent where necessary. It is also your responsibility to notify Flex and Flow of any changes to your health that may impact your ability to participate. * This release is entered into between the undersigned and Flex and Flow Pilates & Yoga and the purpose is to provide fitness exercise and instruction. The undersigned hereby acknowledge and agrees to the following: I acknowledge that the Instructor is not trained in any way to provide medical diagnosis, medical treatment, psychotherapy or any other kind of medical advice. I expressly waive and discharge from any liability of death, disability, personal injury, illness or action of any kind as a result of participating in fitness activities at Flex and Flow Pilates & Yoga. I confirm that I am fit and well enough to attend classes either online or in person. If anything changes in relation to my health that may affect my participation in classes I agree to disclose this to Flex & Flow Pilates and Yoga Yes Sign in the box below * Date * Checkbox * In order to comply with UK GDPR regulations we need your permission to contact you with updates regarding our services and information in our newsletter. You can unsubscribe at any time with the link at the bottom of the email. I give my permission for you to contact me. * Yes No Thank you so much for filling out your health questionnaire.I look forward to seeing you on the mat. Lynne
