Kardy’s Live Classes Screening Form Kardy's Live - 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 ? * Dance Fitness Body Conditioning Flexibility/Stretching Abdominal Blast Upper Body Blast Mindset Training If more than one class, state the one where you will get weighed 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.