Kardy’s Classes Screening Form

If you are human, leave this field blank.

About You

First Name *

Last Name *

Address *

Post Code *

Date of Birth *

Occupation *

Phone number *

Email address *

Please tell us who/where/which advert/what words *

Are you happy to receive news and urgent class notices by email? *

Yes

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Your Health

Have you ever been diagnosed with:

Are you prone to:

Headaches

Fainting

Dizziness

Have you ever suffered from:

Accountable chest pains

Unaccountable chest pains

Please describe chest pains

Please describe pain and limits

Are you or have you been pregnant in the last 3 months? *

Yes

Will exercising in class be new to you? *

Yes

Do you have any known allergies?

Yes

Please describe allergies *

Are you taking any medication? *

Yes

Please describe medication *

Do you have any special needs or any other conditions that may affect your participation in weight management or exercise? *

Yes

Please describe special needs or conditions *

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Your Class

Class Time *

Is there anything else you'd like to tell us?

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Declaration

Assumption of Risk: I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance exercise and stretching. I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me. Should I attend a class led by another instructor I accept responsibility for informing them of, and keeping my instructor updated with any changes to, my medical condition. Additional note: I have taken medical advice and my doctor has agreed that I should exercise. *

I agree and understand

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Prove you are a human