Bounce Back Exercise Assessment
Please take note of the following precautions before taking part in any of our classes. To reduce and avoid injury you need to be sure you are safe to exercise before beginning. For some this may mean consulting your medical practitioner / doctor. By participating in ANY Bounce Back Exercise classes, you are doing so at your own risk.

Bounce Back Exercise cannot be responsible or liable for any injury as a result of our classes. Please be cautious and if at any time you feel faint, dizzy or have any physical discomfort, stop immediately and seek medical advice. Please use good judgement and common sense when taking a class, choose classes suited to your levels of ability, select modifications for your level and rest when you need to.

Please answer all the questions to provide below.

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Full name *
Email address *
Address *
Phone number *
What type of exercise support are you interested in?
Would you like to be added to the Bounce Back Exercise WhatsApp group? (This is a group for members to encourage and motivate one another)
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Date of birth *
Emergency contact name AND telephone number is case we need to contact them *
Name and occupation of person referring or primary health care provider (i.e. doctor, nurse, physio) *
Contact email of person referring/primary healthy care provider *
Please tick below to indicate whether you have been diagnosed with any of the following clinical conditions
Please note any other clinical or physical conditions/ injuries that may impact your tolerance to certain exercises
Are you currently receiving treatment for any injuries or structural problems?
Do you have any of the following health concerns? (Please tick all that apply)
If you answered YES to one more of the above questions, you should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.
Having answered YES to one or more of the questions above, I have sought medical advice and my GP or health care professional has agreed that I may exercise.
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What are your reasons for starting an exercise programme? (Please tick all that apply)
Do you use a walking aid? e.g. stick, lean on furniture, orthotics, functional electrical stimulation
Do you require any seated exercise alternatives?
Please sign below with your name to confirm that you have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury. I understand that this physical activity clearance is valid for a maximum of 12 months from the date that it is completed and becomes invalid if my condition changes. I acknowledge it is up to me to inform my clinical exercise specialist of any changes to my health. *
Can we keep in touch via email? We will let you know the latest Bounce Back Exercise news with exercises to try at home and updates on sessions and events happening. *
How did you hear about us? *
Thank you for completing the assessment questionnaire. Bounce Back Exercise will be in touch with details of how to book your class. You will be sent further information via email on the nature of the sessions and risks involved. Please read this and ask any questions before booking a session. We look forward to seeing you there!
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