Medical Questionnaire

In order to provide adequate care for you whilst attending classes, we require this form to be fully completed before you attend any class.

All the information provided will be entirely confidential.

Your Name (required)

Address (required)

Contact number (required)

Age (required)

Email address (required)

Contact information in case of emergencies. (required)

What class are you attending (required)

Do you have any problems with any of your joints? If the answer is no please type none. If the answer is yes please give details.

Do you have any medication that you may require during a class (eg insulin)? (You will be required to bring this medication to all classes). If the answer is no please type none. If the answer is yes please give details.

Are you pregnant, and if so when is the delivery date?

Have you experienced any complications during this or a previous pregnancy, or is there anything else related to your pregnancy you need to tell us?

Please let us know if you have any of the following conditions? If you have please give further details below. If you do not suffer from any of these please select none.Hypertension (high blood pressure) or hypotension (low BP)Heart disease (eg angina) or other heart conditionHave you had a heart attack (if yes, when?)Epilepsy (major or minor)Stroke (CVA)Diabetes (type I or type II)Have you had, or are you having, treatment for cancer?Do you have eye problems (eg detached retina, glaucoma)?Have you had Menier’s disease?Multiple sclerosisMyalgic Encephalomyelitis (ME)HIVOsteoporosis or osteopenia (thinning bones)AsthmaVaricose veinsAcute anxiety or panic attacksDepressionOtherNone

If you have answered yes to any of the conditions above, please give us further details.

Is there anything else you would like to let us know about your health or the classes?.