Address Medical Questionnaire
Are you currently experiencing OR ever been diagnosed with any of the following conditions?
Please contact Physio&Wellness Hub to discuss suitability of the classes for expectant mums. Have you ever had an episode of Lower back pain? Have you had any recent injuries or surgery?
Which, if any, of the following conditions have you been diagnosed with or had treatment for:
Physical Activity Readiness Questionnaire In order to participate in the Physio&Wellness Hub classes, it is essential that you complete the following questions. Should you answer YES to any of the questions, you should attend your GP for a medical screen regards your suitability and safety for exercise. Evidence of clearance to exercise will then be required, by means of a letter from your GP, before you can attend a Physio&Wellness Hub class. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? Do you feel pain in your chest when you do physical activity? In the past month, have you had chest pain when you were not doing physical activity? Do you lose your balance because of dizziness or do you ever lose consciousness? Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? Do you know of any other reason why you should not do physical activity? Have you done exercise classes before?
What aspects of your health would you like to concentrate on?
Participation Informed Consent These classes will begin at a low level and will be advanced/modified within the class depending on your fitness level and ability. We may stop any exercise session because of signs of fatigue or excessive strain. It is important for you to realise that you may stop when you wish because of feelings of fatigue or any other discomfort. There exists the possibility of certain dangers when exercising; abnormal blood pressure, fainting, irregular, fast or slow heart rhythm, and in rare instances, heart attack, stroke or death. Whilst every care will be taken, it is impossible to predict the body’s exact response to exercise. Every effort will be made to minimise these risks by evaluation of the preliminary information you provide in this form and by observations during exercise. I understand that these Exercise Classes are specifically designed by the class instructor and will take into account details given in my health questionnaire. Therefore, this exercise should only be undertaken in a class setting, or when I have been given specific instructions to exercise on my own. Please note that for publicity purposes, Physio&Wellness Hub may wish to take photos/videos. These photos/videos will be used for media purposes or on the Physio&Wellness Hub Website, publications and/or social media associated with Physio&Wellness Hub. Please also note the cancellation policy: Missed classes will not be refunded and cannot be carried over to any other Physio&Wellness Hub service or set of classes. THIS INFORMATION IS PROTECTED BY THE DATA PROTECTION ACT 1984 I have read and agree to terms*