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DOWNLOAD/PRINT HEALTH QUESTIONNAIRE
Health Questionnaire
Please complete this form before joining a session for the first time.
First name
Last name
Date of Birth
Email
Address
Do you have physical handicaps?
No
Yes
Do you have hypertension or raised blood pressure?
No
Yes
Do you have any conditions associated with heart disease?
No
Yes
Do you have epilepsy or respiratory trouble?
No
Yes
Do you suffer from back trouble?
No
Yes
Do you have arthritis or joint stiffness?
No
Yes
Are you pregnant or have recently had a baby?
No
Yes
Do you have any past injuries that are still affecting you?
No
Yes
Have you had an operation in the last 12 months?
No
Yes
Are you taking any medication?
No
Yes
Do you suffer from stress?
No
Yes
Do you smoke?
No
Yes
How would you describe your diet?
If you answered yes to any question, please elaborate.
I confirm that I am free to participate in this exercise programme and am not acting contrary to the advice of my doctor or any other healthcare professional and that I have revealed, to the best of my knowledge, anything that may affect me as a result.
If I choose not to consult a doctor, I do so at my own risk.
I understand that 24 hours is required to cancel and that all cancellations within this period must be paid in full.
By clicking this box, I agree to adhere to the prevailing terms and conditions of Studio 17 instructors and affiliates.
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