General Health Screening for Yoga/Pilates
Health Screening Questionnaire
Full Name:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Mobile Number:
Your answer
Email:
Your answer
Has your doctor ever said that you have a heart condition and that you should only do exercise recommended by a doctor?
Your answer
Do you experience chest pain when you do physical activity?
Your answer
Is your doctor currently prescribing you drugs for blood pressure or a heart condition?
Your answer
Have you, in the past month experienced any chest pain when you are not doing physical activity?
Your answer
Are you pregnant or breast feeding?
Your answer
Have you ever experienced any of these conditions? Please select any that apply:
Have you/do you attend exercise classes regularly? Please give details below:
Your answer
What is your main motivation for doing my class? (e.g. general fitness, core strengthening, posture, help with back pain, social)
Your answer
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.
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.
Please let me know if you are happy to receive my newsletter and details of events that I am running by email.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy