Fill In The Form . . . Screening Form About You First Name * Last Name * Address * Post Code * Date of Birth * Occupation * Phone number * Email address * Where did you hear about us? Please tick ALL applicable: * Friend Leaflet Poster Advert Web search Facebook OtherOther Please tell us who/where/which advert/what words * Are you happy to receive news and urgent class notices by email? * No Yes End Section Your Health Have you ever been diagnosed with: Heart disease High blood pressure Any other cardiovascular problem Asthma Diabetes Epilespsy Are you prone to: Headaches Fainting Dizziness Have you ever suffered from: Accountable chest pains Unaccountable chest pains Please describe chest pains Do you have any pain or limited movement in: Knee Neck Lower back Hip OtherOther Please describe pain and limits Are you or have you been pregnant in the last 3 months? * No Yes Will exercising in class be new to you? * No Yes Do you have any known allergies? No Yes Please describe allergies * Are you taking any medication? * No Yes Please describe medication * Do you have any special needs or any other conditions that may affect your participation in weight management or exercise? * No Yes Please describe special needs or conditions * End Section Your Class Which class will you be coming to ? * Mon Tues Wed Thu Fri Sat If more than one class, state the one where you will get weighed Class Time * Is there anything else you'd like to tell us? End Section 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 End Section Prove you are a human If you are human, leave this field blank. Kardy Laguda On Line Mindset FOOD & FITNESS Contact Kardy!
