Physical Readiness Health Questionnaire
General Health Form
Soma Pole Studio LLC
Sign in to Google to save your progress. Learn more
Full Name *
Email Address *
Date of Birth (mm/dd/yyyy) *
What is your gender identity? *
What are your preferred pronouns? *
Haven't been asked preferred pronouns before? Just let us know which pronouns you want people to use to refer to you! A few examples are she/her, he/him, and they/them.
Do you have, or have you ever experienced, any of the following (check all that apply): *
Required
Are you taking any medication? If yes, please describe. *
Has anyone in your family ever had a heart problem? *
Have you been admitted to the hospital in the past six (6) months? If yes, please describe. *
Are you pregnant? *
Is there any other reason that this type (pole dance) or any other type of physical activity may not be suitable for you? *
By checking "yes" below, I, the participant, affirm that I have read this form in its entirety and I have answered the questions accurately and to the best of my knowledge. I understand that if the Instructor requires further information about my illness or disability in order for me to safely participate in the activities, I will endeavor to make sure this information is available to him/her/them. I understand that all accidents will be documented, and that I will be informed of the procedures. I have signed the liability waiver and understand that I am participating in this activity at my own risk. I understand that if I choose not to check "yes", I may not be able to participate in the activity. *
In typing my name in the box below, I affirm that all information is complete and accurate:   *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Soma Pole Studio LLC. Report Abuse
Google Forms