Kardy’s Classes Screening Form - Kardy Laguda On Line

About You

Please enter your contact details and an emergency contact below.

Full Name *

Date of Birth *

Phone number *

Email address *

Emergency Contact Name *

Relationship to You *

Emergency Contact Phone Number *

Health & Exercise Screening

Please answer the following questions honestly. This information helps me make your exercise sessions as safe and appropriate as possible.

Has a doctor ever told you that you have a heart condition or that you should only exercise under medical supervision?

Yes

No

Do you experience chest pain during physical activity or exercise?

Yes

No

Have you experienced unexplained dizziness, fainting or loss of balance?

Yes

No

Do you have high blood pressure or another circulatory condition that may affect exercise?

Yes

No

Do you have asthma or another breathing condition that may affect exercise?

Yes

No

Do you have diabetes, epilepsy or another medical condition that may affect your ability to exercise safely?

Yes

No

Have you had any recent surgery, injury or treatment that may affect your ability to exercise?

Yes

No

Do you currently have any joint, muscle, back or mobility problems that could be affected by exercise?

Yes

No

Are you taking any medication that may affect your ability to exercise safely?

Yes

No

Is there anything else about your health or physical condition that you feel Kardy should know before you exercise?

Yes

No

If you answered YES to any of the questions above, please give brief details.

Your Current Activity

A little information about your current activity helps me understand the best starting point for you.

How would you describe your current activity level?

I'm currently inactive

Lightly active

Moderately active

Very active

Are there any exercises or movements that you currently avoid or need to modify?

Yes

No

If yes, please give brief details.

Exercise Declaration

By completing this form, I confirm that the information I have provided is accurate to the best of my knowledge.

I understand that exercise involves physical exertion and that I am responsible for exercising within my own abilities. I will stop exercising if I experience unusual pain, dizziness, chest discomfort, unusual shortness of breath or feel unwell, and seek appropriate medical advice where necessary.

I will let Kardy know if there is a relevant change to my health, medication, injury or circumstances that may affect my ability to exercise safely.

Confirmation

I have read and agree to the Exercise Declaration.

Kardy Fitness Updates

Yes, I'd like to receive occasional Kardy Fitness news, workouts and updates by email.

Prove you are a human

Exercise Screening Form

Before You Begin

About You

Health & Exercise Screening

Your Current Activity

Exercise Declaration

Kardy Laguda On Line