Name *

First Name

Last Name

Do you have heart disease? *

YES

NO

Do you feel pain in your chest when you do physical activity? *

YES

NO

Do you have chest pain when you were not doing physical activity? *

YES

NO

Do you lose balance because of dizziness or do you ever lose consciousness? *

YES

NO

Do you have a bone or joint problem for example Osteoporosis or Arthritis? *

YES

NO

Is your doctor currently prescribing medication for your blood pressure or heart condition? *

YES

NO

Are you pregnant or have been in the past 12 months? *

YES

NO

Have you had a caesarean in the past 12 months? *

YES

NO

Do you suffer with lower back pain? *

YES

NO

Have you had any back or stomach surgery in the last 12 months? *

YES

NO

Please confirm that if you have answered "yes" to any of the above questions, you have checked with a GP that you can carry out this exercise class

I confirm the above