Fitness Without Boundaries - Health Form
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Name : 
Address
Contact phone number 
Email address
Emergency contact name 
Emergency contact Phone number 
Did the health care professional recommend you for this class?
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  if yes to the previous question, please tick which health professional recommended you:  
Name of social prescribing link worker
Health Questions 
  Have you ever been diagnosed by your doctor or health professional with any of the five following medical conditions?  
   Have you ever experienced any of the following?   
  Do you feel pain in your chest when you do physical activity?  
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  Do you ever lose balance of dizziness or even lose consciousness?  
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Do you have medical conditions that we might need to know about in the past year? 
  In the past month, have you had pain in your chest when you were NOT doing any physical activity?  
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  Do you have a bone or joint problem that could be made worse by a change in your physical activity?  
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   Do you have a long-standing illness (i.e: for more than 12 months and likely to continue) or disability which effects (or limits) your day-to-day activities?  
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