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test
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AC
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PMVA HEALTHCHECK FORM
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AVALON CARE TRAINING - PRE-TRAINING HEALTH SCREEN
Have you had a history of, or do you have a, heart condition? NO
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No
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Do you have you a pacemaker fitted?
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No
No
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If yes, please explain: Yes, but we'll managed
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Do you currently have a heavy cold, or do you have a chest infection?
NO
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Have you ever had, or do you currently suffer with Chronic Neurological Disease (e.g. Parkinson’s Disease or Multiple Sclerosis)? NO
No
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Have you a history of or do you currently suffer with dizzy spells or balance problems? NO
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No
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NoIf yes, please explain:
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If yes, please explain:
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Have you a history of, or do you have any, back trouble/pain?NO
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NO
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No
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If yes, please explain:
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If yes, please explain:
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Have you broken any bones in the last year or previously that you feel may affect your ability to take part? NO
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No Do you have arthritis or joint pain of any sort? NO
NO
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NIf yes, please explain:
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No
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No
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NoDo you have noasthma or any respiratonory limitation? NO
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N9Have you ever had, or do you currently suffer with blackouts, fits, epilepsy or fainting?NO
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No
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No No
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If yes, please explain:
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If yes, please explain:
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Are you, at present, on any form of medication that you feel may affect your ability to take part in the course? NO
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If yes, please explain:
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Have you had any operations within the last 6 months that you feel may affect your ability to take part in the course?
NO
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No
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Do you have a prosthesis, joint replaced or implant?NO
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If yes, please explain:
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Have you ever had, or do you currently suffer with hearing difficulties, eye disease or significant eyesight problems?NO
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If yes, please explain:
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NoHave you seen a doctor, or other health care professional, in the last 3 months with any concern that may affect your ability to take part in the course?
NO
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If yes, please explain:
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Are you, or do you think you might be, pregnant?
NO
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If yes, please explain:
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Is there any other reason, physical, emotional or psychological a symptom, condition or limitation that may restrict or prevent you from safely taking part or carrying out Physical Intervention / Restraint or Breakaway physical skills / procedures?
NO
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If yes, please explain:
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No
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7I have read and understood the above information and have completed this questionnaire honestly and
accurately. Yes
I am aware that GSA physical intervention / restraint and breakaway training has a physical element and
agree that, to my knowledge, I am physically able to participate in the training provided. Yes
I understand that it is my responsibility to inform the tutors of any change in my health status prior to
attending or during physical intervention / restraint or breakaway physical skills training. YES
accurately. Yes
I am aware that GSA physical intervention / restraint and breakaway training has a physical element and
agree that, to my knowledge, I am physically able to participate in the training provided. Yes
I understand that it is my responsibility to inform the tutors of any change in my health status prior to
attending or during physical intervention / restraint or breakaway physical skills training. YES
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Date 02/04/26
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Tutor Name:
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AVALON CARE TRAINING - PRE-TRAINING HEALTH SCREEN
Have you had a history of, or do you have a, heart condition? NO
No responses yet for this question.
No responses yet for this question.
No responses yet for this question.
Untitled title
Do you have you a pacemaker fitted?
No responses yet for this question.
No
No
No responses yet for this question.
If yes, please explain: Yes, but we'll managed
No responses yet for this question.
No responses yet for this question.
Untitled Section
Have you ever had, or do you currently suffer with Chronic Neurological Disease (e.g. Parkinson’s Disease or Multiple Sclerosis)? NO
No
No responses yet for this question.
No responses yet for this question.
Have you a history of or do you currently suffer with dizzy spells or balance problems? NO
No responses yet for this question.
No responses yet for this question.
Untitled Title
No
No responses yet for this question.
NoIf yes, please explain:
No responses yet for this question.
If yes, please explain:
No responses yet for this question.
Have you a history of, or do you have any, back trouble/pain?NO
No responses yet for this question.
Yes. I sometimes wake up with pain in my back. But it goes off after a little exercise.
No responses yet for this question.
No
No responses yet for this question.
If yes, please explain:
No responses yet for this question.
No responses yet for this question.
If yes, please explain:
No responses yet for this question.
Have you broken any bones in the last year or previously that you feel may affect your ability to take part? NO
No responses yet for this question.
No Do you have arthritis or joint pain of any sort? NO
NO
No responses yet for this question.
No responses yet for this question.
NIf yes, please explain:
No responses yet for this question.
No
No responses yet for this question.
No
No responses yet for this question.
NoDo you have noasthma or any respiratory limitation? NO
No responses yet for this question.
N9Have you ever had, or do you currently suffer with blackouts, fits, epilepsy or fainting?NO
No responses yet for this question.
No
No responses yet for this question.
No
No responses yet for this question.
If yes, please explain:
No responses yet for this question.
If yes, please explain:
No responses yet for this question.
Are you, at present, on any form of medication that you feel may affect your ability to take part in the course? NO
No responses yet for this question.
If yes, please explain:
No responses yet for this question.
Have you had any operations within the last 6 months that you feel may affect your ability to take part in the course?
No
No responses yet for this question.
No
No responses yet for this question.
Do you have a prosthesis, joint replaced or implant?NO
No responses yet for this question.
If yes, please explain:
No responses yet for this question.
Have you ever had, or do you currently suffer with hearing difficulties, eye disease or significant eyesight problems?NO
No responses yet for this question.
If yes, please explain:
No responses yet for this question.
NoHave you seen a doctor, or other health care professional, in the last 3 months with any concern that may affect your ability to take part in the course?
NO
No responses yet for this question.
If yes, please explain:
No responses yet for this question.
Are you, or do you think you might be, pregnant?
NO
No responses yet for this question.
If yes, please explain:
No responses yet for this question.
Is there any other reason, physical, emotional or psychological a symptom, condition or limitation that may restrict or prevent you from safely taking part or carrying out Physical Intervention / Restraint or Breakaway physical skills / procedures?
NO
No responses yet for this question.
If yes, please explain:
No responses yet for this question.
No
No responses yet for this question.
67I have read and understood the above information and have completed this questionnaire honestly and
accurately. Yes
I am aware that GSA physical intervention / restraint and breakaway training has a physical element and
agree that, to my knowledge, I am physically able to participate in the training provided. Yes
I understand that it is my responsibility to inform the tutors of any change in my health status prior to
attending or during physical intervention / restraint or breakaway physical skills training. YES
accurately. Yes
I am aware that GSA physical intervention / restraint and breakaway training has a physical element and
agree that, to my knowledge, I am physically able to participate in the training provided. Yes
I understand that it is my responsibility to inform the tutors of any change in my health status prior to
attending or during physical intervention / restraint or breakaway physical skills training. YES
No responses yet for this question.
No responses yet for this question.
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Untitled Title
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Date 12/1/25
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Avalon training Tutor Name:
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