Health Questionnaire - Claire Louise Fitness

Personal Details

Name *

Address *

Mobile No. *

Email *

Emergency Name & No. *

What are you hoping to achieve from attending fitness sessions? *

Medical Information

Have you had a major illness or injury in the last 5 years *

Yes

No

Please give details

Do you have a diagnosed medical condition? *

Yes

No

Please give details

Do you take any prescription medication? *

Yes

No

Please give details

Are you currently pregnant or given birth in the past 6 months *

Yes

No

Please give details

Have you experienced Dizzy spells or fainting episodes? *

Yes

No

Have you experienced Palpitations or irregular heartbeat *

Yes

No

Do you have any structural issues? This would include: aches, pains, previous injuries etc *

Yes

No

Please give details and state if it is aggravated by exercise

COVID-19

Have you had COVID – 19? *

Yes

No

When?

Have you suffered with any symptoms of long covid, if so please state what symptoms

Since having COVID-19 have you noticed any changes to your normal level of energy, physical activity or exercise that has been altered or seems to be worsened since your exposure to the virus?

Have you had a COVID-19 vaccination? *

Yes

No

How many vaccines have you had?

Date/s of your vaccines

Confirmation

I can confirm I have read and answered all the above questions honestly and that the information I have included is accurate to the best of my knowledge. I understand it is my responsibility to update Claire Louise Fitness of any new injuries or health conditions.

Full Name *

Signature (Printed) *

Date *

Informed consent for exercise.

All information is kept in the strictest of confidence. If a participant stops participating in Claire Louise Fitness classes, this information will be disposed of in the correct manner.

I confirm that I am aged 15 or over and would like to take part voluntarily in exercise classes in order to attempt to improve my physical fitness.
I confirm I have read and understand what is involved within the classes offered.
I understand that all the exercises should be executed at my own pace and that all activities have progressions and regressions. I understand I should pick a level that is suitable for me and my current fitness levels.
I understand I should follow the instructions given by my instructor at all times, and ensure I perform activities using the correct technique as shown by my instructor.
If I am unsure of any instruction given, I will ask my instructor.
I understand that the cardiovascular activities are designed to place an increasing workload on the heart and lungs and to thereby attempt to improve their efficiency.
Toning exercises will exert muscles which should improve muscular endurance and flexibility exercises should improve/maintain range of motion.
I understand that I am responsible for monitoring myself throughout the class and should any unusual symptoms occur, I would stop exercising and inform the instructor immediately.
I hereby acknowledge that participation in exercise classes involves an inherent risk of personal injury.
In the event of any injuries occurring as a result of attendance to any classes lead by Claire Louise Fitness that she is released from any liability now, or in the future, for conditions that may be obtained from participation.

Face to face classes

Please note future classes must be booked and paid for in advance.
Classes can be cancelled any time up until 24 hours before your session for the class fee to be transferred over to another class. Cancellations after this point will be non-refundable.
I understand online and face to face classes may be filmed for promotional purposes and shared on social media platforms.

In signing this consent form, I confirm that I have read and agree with the conditions of this form as well as acknowledging I have a sound understanding of what is involved in the classes I am participating in. I confirm I have completed a PAR Q/health questionnaire (Physical Activity Readiness Questionnaire) and that all my questions regarding the class have been answered to my satisfaction.