par-q
Pre Activity Readiness Questionnaire
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Name *
email address
Postal Address & Post Code *
Date of Birth *
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would you like to be added to the email list to receive weekly emails with updates of courses/workshops/podcasts/recipes/suggestions to navigate life more positively? (you can subscribe at any time) *
Required
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
Do you feel pain in your chest when you do physical activity? *
In the past month, have you had chest pain when you were not doing physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem (for example, arthritis, osteoporosis etc) that could be    made worse by a change in your physical activity? *
Is your doctor currently prescribing medication? (if yes please advise below) *
Do you know of any other reason why you should not do physical activity?
Clear selection
Are you or have you recently (in the last 6 months) been pregnant? *
Do you have any medical condition that may be affected by exercise?
Clear selection
If you have any medical conditions has your doctor given you clearance to exercise? *
If you have answered yes to any of the above questions, can you please provide relevant details
Have you had any operations that have left scars? (you don't need to give details of operation, but it is useful for me to know locations of any scars you have for mobility)
In relation to your physical well-being, what goals would you like to achieve in the next 6-12 months?
Are there any particular areas of your body that give you any pain/discomfort/tension/feel you need or want to work on?
What type of sessions do you regularly participate in? (please tick all that apply) (with me and/or any other teachers) *
Required
How did you hear about me? *
Is there anything else that you want to let me know/request a discussion about in regards to your class/session?
Formal Declaration: I declare to the best of my knowledge I know of no reason why I should not participate in a personalised programme. I take part in any recommended programme entirely at my own risk and waive any legal recourse for damages or property arising from my participation. Please Note: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions. *
Required
Terms & Conditions 1.   Participants must be over the age of 18 or with parental consent.  2. Anyone with medical conditions must have doctors written clearance. 3.   Any changes to medical conditions / health to be advised to your instructor. 4. Cancellations and changes within 12 hours incur cancellation charges.  5.   No refunds after session / block has started.   6.  A pre activity questionnaire must be completed before initial session.  7.  Jen Wilson (or any teacher covering class) cannot be held responsible for any injuries incurred if participant is not following instruction.  8. Quotes and testimonials may be used for promotional material.  9. Pictures / video footage may be taken during your session for promotional material – please advise if you DO NOT wish your image to be used *
Required
Name (to indicate signiature) *
Date of completing this form *
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