Health Questionnaire - Progress Fitness

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For your safety, it is important that I am aware of your current medical and physical status. Please complete this form as fully as possible. All information provided will remain confidential. Please let me know if any of these details change in the future.

Email *

Name *

Phone number *

Emergency contact name *

Emergency contact phone number *

Please tick if any of the following apply

I have high blood pressure, heart disease, diabetes, epilepsy, breathing problems or bone/joint problems.

I am pregnant, breast-feeding or I have given birth in the last six weeks.

I am currently suffering from an injury or illness.

I suffer with dizziness and fainting.

If you ticked any of the boxes above, please enter further information below

Please list any medication that you are taking below

Is there anything that you feel I should know about e.g. any difficulties with certain movements?

Please tick below to receive a monthly email giving you details of any changes to the class timetable

Email permission

I confirm that I am 16 or over and would like to take part voluntarily in fitness/yoga classes with the aim of improving my fitness. I understand that cardiovascular activities such as Zumba are designed to place an increasing workload on the heart and lungs to help improve their efficiency. Toning exercises in classes such as Yoga exert muscles to help improve muscular endurance and flexibility exercises will help to improve and maintain range of motion. I understand that I am responsible for monitoring myself throughout the class. Should any unusual symptoms occur, I should stop and let the instructor know. There is always a risk of injury when we exercise. I understand the risk of my participation and I release Progress Fitness and Lynne Langmead from any liability now, or in the future, for conditions that may be obtained from participation. By ticking the box below I confirm that I have read this form and I understand the nature of the exercise class(es) I plan to attend. I confirm that any questions that I have, have been answered to my satisfaction. *

Informed consent for exercise participation

Required

A copy of your responses will be emailed to the address you provided.

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