General Health Screening for Yoga/Pilates
Health Screening Questionnaire
Date of Birth:
Has your doctor ever said that you have a heart condition and that you should only do exercise recommended by a doctor?
Do you experience chest pain when you do physical activity?
Is your doctor currently prescribing you drugs for blood pressure or a heart condition?
Have you, in the past month experienced any chest pain when you are not doing physical activity?
Are you pregnant or breast feeding?
Have you ever experienced any of these conditions? Please select any that apply:
high blood pressure
low blood pressure
eye problems/glaucoma/detached retina
surgery within the last 2 years
pregnant/recently had a baby
carpal tunnel syndrome
Have you/do you attend exercise classes regularly? Please give details below:
What is your main motivation for doing my class? (e.g. general fitness, core strengthening, posture, help with back pain, social)
Please check this box to let me know that you agree to me contacting you by email with details of my classes and services and to notify you of any changes to class times or cancellations.
Yes, I agree.
DATA PROTECTION: Please check this box to confirm that you understand that Kim Jones Wellbeing will hold the personal information you provide here securely and will not share this information with any third parties without your prior consent.
Yes, I understand.
Please let me know if you are happy to receive my newsletter and details of events that I am running by email.
Yes, I am happy to receive emails from Kim Jones Wellbeing
No, please do not email me with news and information about events.
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