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Health Questionnaire
If you prefer to print off the questionnaire you can download it
here
.
Health Questionnaire (Informed Consent – Liability Waiver)
Please fill out this form before you start any fitness courses with Jilly B.
Name
*
First
Last
Date of birth
*
Date Format: MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
*
Please tick the box if you answer yes to any of the following questions:
*
Has your doctor ever said you have heart trouble?
Have you ever had pains in your chest?
Do you often feel faint or have spells of dizziness?
Has a doctor said your blood pressure is too high?
Has a doctor said that you might have bone or joint problems, such as arthritis, that has been aggravated or might be made worse by exercise?
Have you been in hospital in the last three years?
Are you currently taking any medication?
Are you Pre/Post natal?
Do you suffer from asthma or breathing difficulties?
Do you suffer from diabetes or epilepsy?
Do you suffer from an allergy? If 'Yes' please mention which medication do you take in the box below?
Is there a good physical reason not mentioned why you should not follow an activity programme?
If you have not recently done so, consult with your doctor before increasing your physical activity and tell your doctor which questions you answered yes to.
If you have answered ‘Yes’ to one or more questions please give details here
How would you describe your current level of fitness?
*
Very fit
Fit
Average
Unfit
How did you hear of JillyB Fitness?
A flyer through my door
Picked up a leaflet from a shop (if so please specify which shop)
Saw an ad in Berkhamsted Living
Through a search engine
Through face book
Through a friend
Other (please specify)
If you selected 'other' please indicate below
*
I agree to the following terms and conditions
In consideration of being allowed to participate in the activities and programmes by Jill Stuart, in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge Jill Stuart of any and all responsibility or liability for injuries or damages resulting from my participation in any activities or my use of equipment or facilities in the above mentioned activities. I understand and am aware that strength, flexibility and aerobic exercise, including the use of equipment are potentially hazardous activities. I also understand that exercise and fitness involve a risk of injury, and that I am voluntarily participating in these activities and using equipment and facilities with the knowledge of the dangers involved. I herby agree to expressly assume and accept all and any risks of injury or illness. I do hereby declare myself to be physically sound and suffering from no condition, impairment, disease or infirmity or other illness (other than those declared on the overleaf medical questionnaire) that would prevent my participation or use of equipment or facilities except as herein started. I acknowledge that I have either had a physical examination and have been given my doctors permission to participate, or that I have decided to participate in activity and use of equipment with the approval of my doctor and do hereby assume all responsibility for my participation and activities, and utilisation of equipment in my activities.
Please type in what you see below
Recent news
Kettlebells outside sportspace at 730 tonight however if it rains we will go inside all saints church hall either at the top or bottom thanks jilly
July 31, 2014
read more
Bootcamp will be taking place this Sunday at 9am not on Saturday. Usual time this evening. Thank you
July 9, 2014
read more
Please complete my online Health Questionnaire here: