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Health Questionnaire - In Person Classes

Andrea Rimington Yoga - Health Questionnaire – Online Classes

Regular physical activity and exercise has many benefits, however, some people should check with their GP before commencing a new activity or before returning to exercise following certain types of injury or illness. Please answer the following questions honestly by circling YES or NO as appropriate.

1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor or as part of a medically supervised programme?

YES/NO

2.  Do you experience unexplained pain in your chest when you do physical activity or at rest?

YES/NO

3. Have you ever lost consciousness due or fallen due to dizziness?

YES/NO

4. Do you have any problems with your back?

YES/NO

5. Are you currently taking any prescribed medication for high blood pressure, a heart condition or other serious illness?

YES/NO

6.  Are you pregnant or have given birth in the last three months?

YES/NO

7.  Have you had surgery recently?

YES/NO

8.  Do you suffer from diabetes/asthma/epilepsy?

YES/NO

9.  Are there any other reasons not mentioned above, why you should only exercise in a medically supervised environment?

YES/NO

10.  Do you currently have any open wounds, sores, infectious skin diseases?

YES/NO

If you have answered “YES” to any of the questions above, please give brief details including recommendations from health professionals (GP, Consultant, Midwife, Condition Specialist, Physiotherapist, etc.). I may require you to obtain doctor’s permission/ advice before undertaking classes. (please fill in more detail on back if needed)

COVID 19 Health Declaration

By coming to the class you are agreeing to make a COVID-19 Health Declaration to confirm that:

-          You do not have any COVID-19 symptoms

-          You have not received a positive test in the last seven days

-          You are not waiting on a Coronavirus test result

-          That no member of your household has COVID-19 symptoms or is waiting on a test                   result

-          And that to the best of your knowledge you have not been in close contact with anyone who is exhibiting Coronavirus symptoms or has tested positive.

I have read and fully understand the Health Questionnaire and the COVID-19 Declaration. I confirm that, to the best of my knowledge, the answers are correct and accurate. I know of no reason why I should not participate in the class. I have understood and answered all of the above questions honestly. I understand that I should not exercise if I feel unwell and if my health changes I should inform my instructor.

Client Name:

Client Signature:

Date: