Health Questionnaire

Please fill out the following Questionnaire before attending your first class (you can also download a PDF version of the form here):

* Indicates required field

Name *

First

Last

Email *

Address *

Phone Number *

Do you have, any physical conditions or injuries that your instructor should know about? *

Yes No

Do you have a tendency to lose consciousness or fall over as a result of dizziness? *

Yes No

Are you on any medication? *

Yes No

Do you have issues with your bones or joints? *

Yes No

Do you have a cardiac condition? *

Yes No

Are you pregnant or have you had a baby in the last 12 months? *

Yes No

Do you have uncontrolled high or low pressure? *

Yes No

Do you have any eye, ear or throat issues? *

Yes No

Do you have varicose veins? *

Yes No

Have you had any operations? *

Yes No

Do you have any type of hernia or prolapse? *

Yes No

Do you suffer any form of menstrual disorder? *

Yes No

Do you have any allergies? *

Yes No

If you answered yes to any of the above please give further details: *

I agree to receiving marketing and promotional materials *

Submit