jo – Exhale Therapy

Health Questionnaire

Regular physical activity is fun and healthy. Being more active is very safe for most people however the questions below will highlight if you should be consulting a doctor before taking part in a Pilates exercise class.

Common sense is always a good guide but please read the questions below carefully and answer honestly:

Has your doctor ever said that you have a heart condition and that you should only do physical activity when recommended by a doctor? Y/N
Do you feel pain in your chest when you do physical activity? Y/N
In the past month, have you had a chest pain when you were not doing physical activity? Y/N
Do you lose balance because of dizziness or do you ever lose consciousness? Y/N
Do you have a bone or joint problem that could be made worse by a change in your physical activity? Y/N
Is your doctor currently prescribing you drugs for your blood pressure or heart? Y/N
Do you know any other reason why you should not do physical activity? Y/N

If you have answered ‘YES’ to any of the above please provide details.

Details

Informed Consent

I, the undersigned, do hereby acknowledge:

My consent to participate in an exercise programme designed by a trained fitness consultant.

My understanding is that exercises will consist of one or more of the following: free body cardiovascular, resistant (strength/endurance) and flexibility

I fully appreciate that there are potential risks involved in participation, e.g. episodes of transient light-headedness or possibly loss of consciousness (highly unlikely) and I assume wilfully these risks

I understand that I may stop or delay any exercise if I so desire and that the class may be terminated by the instructor upon observation of any symptoms of undue distress or abnormal response.

My understanding is that I may ask any questions or request further explanation or information about the procedures at any time before, during and after the training.

That I have read, understood and completed the medical screening questionnaire and obtained medical clearance if necessary.

I hereby sign below to confirm that I provide full consent to participate in the proposed activities and that, by doing so, I accept the risks identified above. I also understand that I may withdraw from the class at any time.

Name (Digital Signature Acceptance)

Date

I understand the Health Questionnaire

I hereby confirm that I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.

Email Address

Author name: jo

740e3cee14e46117c6068d29fea46619

740e3cee14e46117c6068d29fea46619

740e3cee14e46117c6068d29fea46619

740e3cee14e46117c6068d29fea46619

740e3cee14e46117c6068d29fea46619

740e3cee14e46117c6068d29fea46619

CONTACT

CLINIC ADDRESS