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Kardy’s Classes Screening Form
If you are human, leave this field blank.
Date of Birth
Where did you hear about us? Please tick ALL applicable:
Please tell us who/where/which advert/what words
Are you happy to receive news and urgent class notices by email?
Have you ever been diagnosed with:
High blood pressure
Any other cardiovascular problem
Are you prone to:
Have you ever suffered from:
Accountable chest pains
Unaccountable chest pains
Please describe chest pains
Do you have any pain or limited movement in:
Please describe pain and limits
Are you or have you been pregnant in the last 3 months?
Will exercising in class be new to you?
Do you have any known allergies?
Please describe allergies
Are you taking any medication?
Please describe medication
Do you have any special needs or any other conditions that may affect your participation in weight management or exercise?
Please describe special needs or conditions
Which class will you be coming to ?
If more than one class, state the one where you will get weighed
Is there anything else you'd like to tell us?
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
Prove you are a human