Health Form

Please fill in this form before taking part in any Core Intention Classes.

Please take a moment to fill out the form.

First Name

Last Name

Phone

Date of Birth

Emergency Contact Name

Emergency Contact Number

Has your Doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had any chest pain at any time, whether physically active or not?

Do you have a bone or joint problem that could be made worse with a change in physical activity?

Are you taking any prescribed drugs?

Do you suffer with dizziness or feel faint? If yes, please provide more details.

Do you have any hernias?

Are you pregnant?

Do you know of any reason why you should not participate in a physical activity programme? If yes, please provide more details.

If you answered yes to any of the above, please make an appointment with your doctor, if you have not recently had a consultation, to discuss your suitability for Unrestricted physical activity, or restricted or supervised activity to meet your specific needs.

I hereby state that I have read and understood the questions above. I wish to participate in activities which may include aerobic exercise, resistance exercise and stretching. I accept there is always a chance of injury when taking part in physical activity and do so at my own risk.

I hereby state that I consent for Tania Stanfield, Core Intentions, to store my personal details. I understand this is optional and if i make the decision to stop attending classes, my records can be stored for a further 6 months. I understand I can opt-out at any time by sending an email to tania.stanfield@hotmail.co.uk.

Your Signature

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Health Form

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