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MFF 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 relevant notices by email? *

No

Yes

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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 doing activity 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 mindset, weight management or activity? *

No

Yes

Please describe special needs or conditions *

Contiinue below

Anything Else?

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

Continue below

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 nutritional changes, 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

If you are human, leave this field blank.