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FREESTYLE FITNESS YOGA HEALTH SCREENING FORM

Name: ……………………………………………………………………………………………………….............................

 

Address: …………………………………………………………………………………………………………………………..

 

Contact Number: ……………………………………….……………………      Date of Birth: ……./……../………….

Email address:……………………………………………………………………………………………………………………..

Occupation: ………………………………………………………………………………………………………………………..

● Do you suffer from back problems?    YES / NO.   If yes, please give details:…………………………………….

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● IF you have back problems now, are you receiving treatment from a Physiotherapist, Chiropractor,      Osteopath or any other professional ….. YES / NO.   If yes, please give details, name and contact number: …………………………………………......................................................................................

● Have you ever had treatment for a back problem?    YES / NO   Details: ……………………………………

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● If necessary, have you been given medical clearance to attend a FFY class?           YES / NO

 

● Are you suffering from ANY other medical problems that may affect your ability to exercise? -

   YES /NO   Details: …………………………………………………………………………………………………………….

 

● Have you any additional Health information that may be relevant?  YES / NO   Details: ………………..

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● How do you rate your overall posture – please circle one & give details:

 

 Please circle:  Excellent,  Average,  Poor,  Very Poor     Details:……………………………………………

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Do you currently exercise?  YES / NO.    If yes, type of exercise and how often?.......................................

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Informed Consent:

I understand that whilst every care will be taken to give safe instruction, I accept full responsibility and consider myself fit to take part in this class.  I have answered all the questions correctly and all medical and health considerations are noted above.  I understand that I attend Freestyle Fitness Yoga classes at my own risk.  I will keep the instructor updated.

 

Print your name: ………………………………………………………………………………….

 

Signature: …………………………………………………………………………………               Date: ……/……/………….