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Health Form

Important Notice

  1. Always consult your doctor or health professional before undertaking a new exercise regime.
  2. This Health Form must be completed in full and submitted at least 1 working day before the start of your course.

Health Form

    Who Should We Contact in Case of Emergency?

    Medical Issues

    Have You Had Surgery in the Last 10 Years?


    YESNO

    Have you suffered, or do you suffer, from any of the following:

    AsthmaDiabetes (Type 1/Type 2)EpilepsyHigh/Low Blood PressureFainting/Dizziness/HeadachesHeart ConditionHearing Loss
    ArthritisBack ProblemsHip ReplacementKnee ReplacementShoulder ProblemsOther Joint Problems

    Are You Pregnant?

    YESNO

    Any Other Conditions That May Affect Your Ability To Exercise in a Group?

    YESNO

    Daily Activities


    Declaration

    I acknowledge that I am fully responsible for:

    1. monitoring my capability to participate in any exercise session

    2. advising ActiveQi of any health or medical conditions that may affect my participation

    I have answered the questions accurately and to the best of my ability:

    I understand the questions on this form: