Health Questionnaire

Name

D.O.B

Address

Email address

Mobile Number

Landline

Emergency Contact Name

Emergency Contact Number

Emergency Contact Name 2

Emergency Contact Number 2

Has your doctor ever said you have a heart condition, including high blood pressure? If yes, please give details:

Have you ever had a stroke or T.I.A? If Yes, please give details:

Do you have, or have you ever had cancer? If yes, please give details:

Do you have diabetes? If yes, please tick which type:

IDDM NIDDM

Do you have any joint problems including osteoporosis? If yes, please give details:

Do you ever lose your balance because of dizzy spells or do you ever lose consciousness? If yes, please give details:

Do you have any respiratory conditions such as asthma or C.O.P.D? If yes, please give details:

Do you have epilepsy?

Yes No

Does your doctor prescribe any medication for you? If yes, please give details:

Do you have any visual or hearing impairments? If yes, please give details:

Is there anything else relevant that is not listed above?

Has your doctor ever said you should not partake in exercise? If so why?

Where did you hear about C.O.A.F?

Please sign below

By checking the box and proceeding, I am electronically signing this Agreement, effective as of today’s date. By signing this form I give consent for my personal data to be collected and retained securely by C.O.A.F for the purpose set out in its Data Privacy Statement available to read here.

Lucinda has many years experience in exercising older adults and has a wealth of knowledge around illnesses and conditions that come with older age… Find out more

Health Questionnaire

Please complete this form prior to taking part in one of my classes.