Health & Emergency Contact Form

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Please complete the following health questionnaire before attending your first class and periodically when requested so we can ensure our records remain accurate and up to date.

This information helps us deliver classes safely and appropriately. Please ensure the details you provide are accurate and inform your instructor of any changes to your health, injuries, or ability to exercise before participating in sessions.

First name *

Surname *

Address *

Postcode *

Phone number *

Email address *

Gender

Male

Female

Prefer not to say

Clear selection

How did you find out about us? If you were referred, who by? *

Already attend a Fitness Without Boundaries/Yes To Being Fit class

Self - referred

Word of mouth

Social prescribers

Spring

Social media

Website

Doctor

Nurse

Physio

Consultant

Any other health care provider

Other:

Reason for referral if applicable - please select all that apply. Please give a brief description below.

Mental health

Arthritis

Back problems

Diabetes (controlled)

Asthma (controlled)

Blood pressure (checked by doctor)

Balance issues

Pre / post natal

Mild COPD

Neuro disease

Heart problems

Disabilities

Cancer

Stroke

Brain injury

Weight management

Other:

Please give a brief description.

Do you use any walking aids? *

Walking stick

Walking frame

Crutches

Wheelchair

Other:

Required

How often do you exercise?

Which service are you interested in? *

Village Yoga

Village Pilates

Chair Yoga

Chair Pilates

Gym rehabilitation sessions

Stretch & Beyond (Get Up and Go: Anti -falls classes)

1-2-1 - Exercise rehabilitation

1-2-1 - Yoga or Pilates

Other:

Required

Please provide any additional health information you deem relevant.

Emergency contact name *

Emergency contact number *

In the event of an accident, illness, or medical emergency during a class, do you give permission for the instructor to administer first aid and seek appropriate medical assistance if required? *

Yes

I have answered all questions in this form honestly and understand that, if relevant, I should consult my GP before commencing an exercise programme. If I am affected by any of the conditions mentioned in this form now or at a later date, I agree to inform my instructor of any changes in my health or fitness.

I understand that participation in exercise carries an element of risk and that I take part voluntarily. I will follow the instructor’s guidance and inform them of any pain, discomfort or injury.

I am happy to be added to the mailing list and WhatsApp group and to be contacted using the details submitted above. *

Tick that you understand and agree to this form

Required

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