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Pre-Class / Workshop Questionnaire
As you are the planning to take part in physical activity please answer the questions below. If you are between the ages of 16 and 69, the questionnaire will tell you if you should consult with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. All information will be treated confidentially.
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Indicates required field
Which Workshop or Classes are you signed up for?
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Back Care Yoga Classes
Neck and Shoulder Workshop
Name
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First
Last
Phone Number
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Email
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Emergency Contact Name
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Emergency Contact Phone Number
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What types of exercise do you currently do?
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How would you describe your current fitness levels?
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Health Information
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
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Yes
No
Have you ever had chest pain when you were not doing physical activity?
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Yes
No
Do you have high blood pressure?
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Yes
No
Do you have a joint problem that could be made worse by exercise?
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Yes
No
Is there any other reason why you should not participate in this workshop?
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Yes
No
Do you ever feel pain in your chest when you do physical activity?
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Yes
No
Do you ever feel faint or have spells of dizziness?
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Yes
No
Are you currently taking any medication which I should aware of?
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Yes
No
Are you pregnant, trying to get pregnant or had a baby in the last 6 months?
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Yes
No
Not applicable
Do you have problems getting up and down from the floor?
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Yes
No
If you have answered Yes to any of the above questions then please give further details:
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If you have answered 'NO' to all questions
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You can be reasonably sure that you can take part in the workshop.
Please note:
If your health changes so that subsequently you answer yes to any of the above questions, please let me know before the workshop.
Any Comments?
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How did you hear about this workshop?
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I have read and fully understand this questionnaire. I have answered all questions to the best of my knowledge. My participation in the workshop is voluntary and entirely at my own risk. I will only participate in the workshop at an exertion level that I am comfortable with and will stop exercising immediately if I feel discomfort or am experiencing any pain and I will inform the instructor of my symptoms. I understand that I am free to withdraw from the activity at any time.
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