Amy Moore – Older Adults Registration Form

Amy Moore

Services
About
- Postnatal
  Screening Form
- Older Adults
  Registration Form

Services
About
- Postnatal
  Screening Form
- Older Adults
  Registration Form

Older Adults Registration Form

PRE EXERCISE QUESTIONNAIRE

Contact Information

Name

Age

Phone number

Address

Emergency contact and phone number

Medical Information

Have you been diagnosed with a heart condition and advised that you should only do exercise recommended by your doctor?

Yes No

Do you have high blood pressure?

Yes No

Do you have low blood pressure?

Yes No

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?

Yes No

Do you ever feel faint/dizzy or lose balance during physical activity/ exercise?

Yes No

Have you been diagnosed with muscle, bone or joint problem that you have been told by a medical professional could be made worse by participating in exercise?

Yes No

Do you have any other conditions that may require special consideration for you to exercise?

Yes No

Do you have any current injuries or problems which currently affect your ability to undertake some movements or exercises (brief outline)

Terms & Conditions

I confirm that I understand the above questionnaire and to my knowledge the information is correct. Whilst I understand that all care will be taken for my safety by the centre, I exercise at my own risk. I believe to the best of my knowledge that all of the information I have provided on this form is accurate. In the case that any of the information I have provided changes over the course of my training, I will inform my trainer and discuss whether the class is still suitable for me.

Date

Client signature