NEW MEMBERS WELCOME FORM

INFORMED CONSENT

If you suffer from any form of photosensitivity or light sensitivity please let the instructor know as flashing lights are used in some classes.

 

Listen to your body, take the class at your own pace and choose lower impact options if you find the high impact moves too challenging. It is vital you stay hydrated during the class, have a drink whenever you need it.

I, the below mentioned, understand that there is a risk of injury associated with participating in the exercise classes. Participation in such class is therefore at my own risk and without any recourse to the instructor or Fitjess Fitness.  

 

All activities will be explained and demonstrated for you and you will have teaching points mentioned repeatedly during your workout to help keep your exercise form to its best. Please notify the instructor if for any reason you feel you should not partake in any part of the session. The structure, purpose, benefits and risks of the session have been explained to me and I understand that I am free to withdraw from the programme at any time.

 

I understand I am to consult my physician, doctor or other healthcare provider before varying or starting an exercise program and exercise class.  I am to inform the instructor directly of any healthcare issues prior to undertaking the exercise class.  

MEDICAL HISTORY (please circle your answers)

 

1. Have you ever suffered with epilepsy?                                                                                      YES / NO

WARNING: Flashing lights may be used in this class                                                            

 

2. Are you pregnant? If yes, how many months? ...........                                                             YES / NO

 

3. Have you ever suffered from heart trouble?                                                                            YES / NO

 

4. Are you presently taking any form of medication?                                                                  YES / NO

 

5. Do you suffer from chest pains?                                                                                                 YES / NO

 

6. Do you ever have spells of dizziness or feel faint?                                                                  YES / NO

 

7. Have you ever had either high or low blood pressure, and/or high cholesterol?              YES / NO

 

8. Have you ever had asthma, chronic bronchitis or any other chest ailments?                    YES / NO

 

9. Do you suffer from severe back pains or any orthopaedic problem?                                  YES / NO

 

10. Do you suffer from severe headaches or migraines?                                                           YES / NO

 

11. Are you recovering from a recent illness / operation or injury?                                          YES / NO

 

12. Have you any medical condition that we should be aware of?                                            YES / NO

 

13. Is there any history of heart disease in your immediate family (before age 55)?             YES / NO

 

14. 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

PLEASE NOTE: If you have answered YES to any questions 1 - 14, you are advised to seek medical advice/approval before taking part in this class.

 

I have been informed that if I answer YES to any of the questions 1 - 14 of the questionnaire I should seek medical advice/approval before commencing this class. If I wish to continue without such advice I do so entirely at my own risk. I confirm that I have read, fully understood and answered honestly.

 

I understand the nature of the class and confirm that I am in proper physical and mental condition to participate. If at any time I have questions, feel unsafe or unwell I will immediately inform the Instructor (or their assistant) and discontinue further participation in the class.

 

I agree to assume full responsibility for any and all injuries, losses and damages that I incur while attending, exercising or participating in each exercise class and for those that I cause to others.

I hereby waive all claims against Jessica Tomkins or other instructors and Fitjess Fitness, individually or otherwise, for any and all injuries, claims or damages that I might incur or be the cause of.

 

I have read, understood and agree to the terms of this form by signing:

CONTACT

fitjessfitness@yahoo.com

Tel: +44 (0) 7786 522 934

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