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Please read carefully: Tick YES or NO. If you tick any of the ‘yes’ responses below you may need your doctor’s consent before you participate in a FitSteps class.
1. Has a doctor ever said that you have a heart condition and not to take part in physical activity? Yes No 2. Do you have chest pain brought on by physical activity? Yes No 3. Have you developed chest pain in the last month? Yes No 4. Do you lose consciousness or fall over as a result of dizziness? Yes No 5. Do you have a bone or joint problem that could be aggravated by physical activity? Yes No 6. Has a doctor ever recommended medication for your blood pressure or a heart condition? Yes No 7. Are you aware through your own experience or from doctor’s advice of any other reason why you should not do physical activity without medical supervision? Yes No
Please outline any other relevant information that may affect your ability to exercise.
Known allergies:
Pre-existing medical conditions:
Current medication:
Informed consent: I realise that my body’s reaction to physical activity is not totally predictable. Should I develop a condition that affects my ability to exercise, I will inform my instructor immediately and stop exercising if necessary. I take full responsibility for monitoring my own physical condition at all times.
If you have answered ‘YES’ to any of the above questions, are pregnant, have a history of heart disease or suffer from any other medical condition, we strongly recommend that you obtain your doctor’s consent that you many take part in this class/training event.
You agree by signing below that: you are taking part in this class/training event at your own risk and FitSteps will not be responsible for any injury or loss or harm of any kind that may result directly or indirectly from you taking part in this class/training event, other than death or personal injury caused by negligence.
In Case of Emergency who would we contact?
Name: Relationship to the participant: Contact no.:
By checking this box you agree to be contacted by FitSteps LTD regarding events and opportunities that may be of interest to you. We will not use your data for any other purpose and we will never share your data with third party organisations. Agree
Signature: You can use your mouse cursor or your finger if you have a touch screen. Signature below
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