Health Questionnaire

Full Name:

Mobile Number:

Email Address:

Emergency Contact Name:

Emergency Contact Number:

Medical Details

Please answer yes or no. Some questions may require some more detail if answered yes.

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes

2. Do you feel pain in your chest when you do physical activity?

Yes

3. Do you have high or low blood pressure?

Yes

If yes, please specify high or low.

4. Are you pregnant?*:

Yes

5. Do you suffer from fainting or dizziness?*:

Yes

6. Have you had any recent surgery?*:

Yes

If yes and was within the last 12 months, please detail what the surgery was and when:

7.Do you have any muscle, bone, joint problem, back or other previous injury still affecting you or that could be made worst by a change in physical activity?*:

Yes

If yes, then please give details:

8. Are you diabetic?

Yes

9. Are you on any medication?

Yes

If yes, then please give details:

10. Is there anything else that you feel is relevant for us to know before you take part in any physical activity?

Yes

If yes, then please give details:

Health question summary

If you have answered:

YES to one or more questions: please discuss with your instructor. You may have to talk to your doctor by phone or appointment before you start becoming more physically active.

NO to all questions: You can be reasonably sure that you can start becoming more physically active beginning slowly and build up gradually from your current ability level.

If your health changes so that you answer YES to any of the above questions, you MUST tell your instructor.

Declaration

I have read and understood the health questionnaire. I have informed the instructor of any or all medical details. I agree to undertake any given activity at High at my own risk and am aware my participation involves a risk of injury. I will inform the lead instructor of any changes to the above details. I confirm I take full responsibility for any risk, injuries or damages known or unknown which I may incur as a result of my participation in the sessions with Snowdrop House.

I agree to the terms and conditions:

I acknowledge having agreed to receiving fitness sessions through Snowdrop House. No guarantee given or implied. The trainer will endeavour to ensure that sessions are conducted, as much as possible, at agreed dates and times. I agree to attend as agreed and to provide reasonable notice (48 hours if possible) in the event of being unable to attend. Any session recording or support material provided, is free of charge, and only provided with my agreement and at the trainer’s discretion. If it has been requested, by my trainer to seek consent from my medical doctor/consultant, then I have done so or will do so prior to the sessions. It is my responsibility to update my trainer with any changes to my medical health. Under extreme circumstances, my practitioner may liaise, in writing or verbally with my GP and I may request a copy of such communication. Snowdrop House strongly recommends that you consult your doctor and obtain medical clearance prior to commencing any exercise programme, as a certain level of risk is inherit in any exercise programme. Any information, instruction or advice obtained from the Snowdrop House team may not be substituted for your doctor’s advice or treatment, and that any instruction or advice is obtained at your own risk. You agree to release and discharge Snowdrop House, it’s staff and directors from any and all responsibilities or liabilities from injury or illness arising from your participation in any activity undertaken at Snowdrop House or upon our advice.

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