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: