Health Questionnaire - In Person Classes

Andrea Rimington Yoga - Health Questionnaire – Online Classes

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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.

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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

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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)

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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: