Medical Form

Your Details


Current Medical History

Do you have Diabetes?
If yes, are your glucose levels currently normal and under control?
High or blow blood pressure (BP)?
If high or low, do you use medication (including beta-blockers)?
Do you have any cardiac or heart problems?
If yes, have you had an exercise stress test?
Do you have asthma or other breathing difficulties or issues?
If yes, is your condition stable?
Do you require regular medication during exercise?
Do you have Epilepsy?
If yes, are seizures stabilised with medication?
Do you suffer with digestive complaints (i.e. ulcers/reflux/colitis), or bowel/bladder dysfunction?
Have you been disagnosed with osteopenia/osteoporosis?
Do you suffer from any bone or joint problems (i.e. arthiritis, rheumatism, or hyper mobility)?
Have you been diagnosed with any form of cancer?
Do you have any present injury?
If yes, have you been cleared to exercise by your doctor?
Have you had any problems with your vocal chords, voice box or larynx? Diagnosed or not?

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?
Have you had any surgery?
Have you had any neck, spine or lower back issues or injuries?
Have you had any joint problems or injuries?
Have you had any other muscle, ligament or tendon problems or injuries?
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.

Pregnancy History

Are you, or could you be pregnant now?
Have you had any previous pregnancies?
Have you had any episiotomies?

Movement History

Are you taking any medications not already mentioned in this questionnaire that may impact your ability to exercise safely?
Is there a history of ill health in your family (heart disease, cancer, diabetes etc)?

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.