Physical Readiness Questionnaire
All students are required to complete this questionnaire so that we can communicate with you about classes you have signed up for and in order to comply with our insurance and health and safety requirements. If you are between the ages of 15 and 69, this questionnaire will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, please check with your doctor before commencing classes.
When you have finished please press the 'submit' button at the end of the document.
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Email *
First name *
Surname *
Date of birth (DD/MM/YY)
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Postal address *
Telephone *
Do you have any conditions that might cause us to need to summon medical attention? 
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If yes, please specify
Do you have injuries or physical conditions that need to be taken into consideration?
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If yes, please specify
Please read each of the following questions carefully and answer honestly by indicating YES or NO.
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
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Do you feel pain in your chest when you do physical activity?
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In the past month, have you had a chest pain when you were not doing physical activity? 
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Do you lose balance because of dizziness or do you ever lose consciousness?
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Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity?
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Is your doctor currently prescribing medication for your blood pressure or heart condition?
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If you answered YES to one or more 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.
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If you answered NO to ALL of the questions, it is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.
Do you know of any other reason why you should not take part in physical activity?
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Declaration

By entering the date and clicking submit below, I confirm that the information given is correct at the time of submission and that I will inform you if this information needs updating at any time. I 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. If I have answered yes to any of the questions, I understand that I cannot attend classes without having first sought medical advice and agreement from my GP that I may safely exercise. 


In addition to this health declaration, I understand that these classes are not aimed at teachers. Attendance is by no means tacit approval for a person to go on and teach and that by signing this form I declare that I do not teach Tai Chi or Chi Kung or Hsing I nor intend to profit from teaching them.
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Required
Today's date (DD/MM/YY) *
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SIGNATURE 
To be signed in person at your first class. You don't need to print this form out, I will bring a copy for you to sign. Thank you for completing the questionnaire.
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