HEALTH SCREENING FORM

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Tracey Telfer Fitness at home

Your Name *

Date of Birth *

YYYY

Mobile

Email address *

Have you ever been diagnosed with any of the following medical conditions?

Heart Disease

High Blood Pressure

Other cardio-vascular problems

Diabetes

Asthma

Epilepsy

Other:

Do you suffer from pain or limited movement in these joints?

lower back

neck

knee(s)

hip(s)

Other:

Are you pregnant, or have you had a pregnancy, in the last 3 months?

yes

Clear selection

Have you had a baby in the last 3 months?

yes

Clear selection

Are you used to exercising?

yes

yes but not exercised for some time

Clear selection

If you have answered YES to any of these questions, Tracey will need to speak to you about whether she feels it is appropriate for you to participate in our online classes. An adaptation/alternative may be all that is needed for you to proceed safely and effectively. However, it may be more appropriate for you to consult your GP prior to starting.

I declare that to the best of my knowledge I have answered these questions correctly. Should my medical circumstances change, I accept the responsibility of keeping Tracey informed. PLEASE SIGN YOUR NAME BELOW. *

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