Informed Consent For Classes

Name *

First

Last

Date of Birth *

YYYY/MM/DD

Email *

Mobile number *

Please include your country code if not in the UK e.g. 0081

Address *

Emergency Contact *

(Name and Email/Mobile Number)

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes
No

Do you feel pain in your chest when you do physical activity? *

Yes
No

In the past month, have you had a chest pain when you were not doing physical activity? *

Yes
No

Do you lose you balance because of dizziness or do you ever lose consciousness? *

Yes
No

Do you have a bone or joint problem (for example, back, knee, or hip) that could be made worse by a change in your physical activity? *

Yes
No

Is your doctor currently prescribing medication for your blood pressure or heart condition? *

Yes
No

Do you know of any other reason why you should not do physical activity? *

Yes
No

If YES, to the last question please comment below:

If you answered YES to one or more of the above 7 questions, you should confirm with your doctor whether it is safe for you to become physically active at this time and at your current stage of health. If you answered NO to ALL the above 7 questions, it is reasonably safe for you to participate in physical activity, gradually building up from your current ability. If anything changes and your answer to any of these questions becomes a YES, please inform Belly Strong immediately as your ability to participate in physical activity will need to be reviewed.

Do you have any of the following? (Please check if YES) *

If you are currently pregnant, please select the number of weeks you are. If you are not pregnant, please skip.

Selected Value: 4

Please select the number of weeks you are from 4 weeks to 42 weeks.

If you are currently pregnant, have you experienced/been diagnosed with any of the following? (Please check if YES).

If you have given birth within the past 1 year, please provide the date of delivery and what kind of delivery you had. If not, please skip.

e.g. YYYY/MM/DD, Vaginal delivery with epidural

Are you on any medications? If YES, please list them below. If NO, please skip.

Do you have anything else you'd like to add about your medical/physical fitness history? If so, please elaborate below.

Signature

All clients are required to fill out a medical questionnaire and informed consent before participating in any exercise or Pilates class. This is to ensure your safety at all times. Please answer all questions fully and truthfully. All information will be kept strictly confidential.

Informed Consent

Purpose

Risks

Benefits

Recording of Sessions & Photos

Confidentiality

Withdrawal of Consent

Questions

Physical Activity Readiness Questionnaire and Medical History

Declaration