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Fitness Without Boundaries - Health Form
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Name :
Your answer
Address
Your answer
Contact phone number
Your answer
Email address
Your answer
Emergency contact name
Your answer
Emergency contact Phone number
Your answer
Did the health care professional recommend you for this class?
Yes
No
Other:
Clear selection
if yes to the previous question, please tick which health professional recommended you:
Doctor / Nurse
Physiotherapist
Supporting Independence Programme Heath
Falls Clinic
Social Prescribing Link Worker
Name of social prescribing link worker
Your answer
Health Questions
Have you ever been diagnosed by your doctor or health professional with any of the five following medical conditions?
Heart disease
High Blood Pressure
Chronic Obstructive Pulmonary Disease (COPD) or
Emphysema and Chronic Bronchitis
Diabetes
Asthma
Have you ever experienced any of the following?
Has your doctor ever said you have a heart condition?
yes
No
Do you feel pain in your chest when you do physical activity?
Yes
No
Maybe
Clear selection
Do you ever lose balance of dizziness or even lose consciousness?
Yes
No
Maybe
Clear selection
Do you have medical conditions that we might need to know about in the past year?
Your answer
In the past month, have you had pain in your chest when you were NOT doing any physical activity?
Yes
No
Maybe
Clear selection
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes
No
Maybe
Clear selection
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?
Yes
No
Prefer not to ask
Clear selection
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