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RP&Y Health Questionnaire 2021
Please read the questions carefully and answer each one honestly completing the information as necessary. Your responses will be kept in the strictest confidence. this form must be completed and returned prior to attending an online or studio session.
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Email
*
Your email
Full Name
*
Your answer
Telephone number
*
Your answer
Emergency contact name and number
*
Your answer
Has your doctor ever said...
*
You have a heart problem/condition
You have suffered with chest pain
You have suffered from any bone or joint problems/conditions
You have had blood pressure problems (high or low)
None of the above.
Other:
Required
Thinking about the above question, if you have ticked any, please explain here. Include current treatment and medication. (This will be kept strictly confidential.)
Your answer
Do you have or have you ever had; any major injuries, operations (in the last 5 years) or illnesses? Please consider broken bones, any physical condition which may impact your ability to exercise. If yes, please explain below.
Your answer
Are you pregnant? Or recently had a baby (in the last 12 months)? If so please give relevant information.
Your answer
I believe that to the best of my knowledge that all the information I have supplied within this form is correct. I will inform my instructor if anything changes and I understand that I partake in any physical activity at my own risk.
*
Yes
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