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V VIBRATION HEALTH & MEDICAL QUESTIONNAIRE
Medical Form
Your Details
Name
Name
First
First
Last
Last
Date of Birth
Gender (not required)
Email
Address
Mobile Number
Work Telephone
Home Telephone
Current Medical History
Do you have Diabetes?
Yes
No
If yes, please specify whether IDDM or NIDDM (diet or medication controlled)
If yes, are your glucose levels currently normal and under control?
Yes
No
Not Applicable
High or blow blood pressure (BP)?
High
Low
Not Applicable
If high or low, do you use medication (including beta-blockers)?
Yes
No
Not Applicable
Do you have any cardiac or heart problems?
Yes
No
If yes, have you had an exercise stress test?
Yes
No
Do you have asthma or other breathing difficulties or issues?
Yes
No
If yes, is your condition stable?
Yes
No
Do you require regular medication during exercise?
Yes
No
Do you have Epilepsy?
Yes
No
If yes, are seizures stabilised with medication?
Yes
No
Do you suffer with digestive complaints (i.e. ulcers/reflux/colitis), or bowel/bladder dysfunction?
Yes
No
Have you been disagnosed with osteopenia/osteoporosis?
Yes
No
Do you suffer from any bone or joint problems (i.e. arthiritis, rheumatism, or hyper mobility)?
Yes
No
Have you been diagnosed with any form of cancer?
Yes
No
If yes, please specify:
Do you have any present injury?
Yes
No
If yes, have you been cleared to exercise by your doctor?
Yes
No
Have you had any problems with your vocal chords, voice box or larynx? Diagnosed or not?
Yes, diagnosed
Yes
No
If yes, please specify:
Past Medical History
Please answer 'yes' or 'no' to the following question and provide a brief explanation in the space provided.
Have you been involved in any major accidents, including motoring accidents?
Yes
No
If yes, please specify:
Have you had any surgery?
Yes
No
If yes, please specify:
Have you had any neck, spine or lower back issues or injuries?
Yes
No
If yes, please specify:
Have you had any joint problems or injuries?
Yes
No
If yes, please specify:
Have you had any other muscle, ligament or tendon problems or injuries?
Yes
No
If yes, please specify:
Is there any other condition or disability not covered above, that we should be aware of when working with you? Activities will include lying, sitting, bending, and a certain amount of muscle stregthening and breathing exercises.
Yes
No
If yes, please specify:
Pregnancy History
Are you, or could you be pregnant now?
Yes
No
If yes, please give a due date if applicable:
Have you had any previous pregnancies?
Yes
No
If yes, please specify how many and give details if delivery was natural, by caesarian or forceps etc.
Have you had any episiotomies?
Yes
No
Movement History
Please provide details of any exercise, movement or other sports activities undertaken currently and/or practiced from childhood. Please include frequency:
Are you taking any medications not already mentioned in this questionnaire that may impact your ability to exercise safely?
Yes
No
If yes, please give details:
Is there a history of ill health in your family (heart disease, cancer, diabetes etc)?
Yes
No
If yes, please give details:
Terms & Conditions
The physical programme we provide is based upon sound teaching practice and the information you have provided about yourself when filling in this health & medical questionnaire.
Therefore, please inform us about any change in your medical/health condition as soon as you become aware of it.
When exercising, you must follow the instructions of the instructor at all times.
By submitting this form, I decalre that I have answered all the questions provided truthfully, comprehensively, and to the best of my ability. I accept the above terms and conditions and agree to abide by them.
Signed (Name):
Date
If you are human, leave this field blank.
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