PLEASE PRINT THEN FILL THIS HEALTH QUESTIONNAIRE AND GIVE IT TO ONE OF THE FMC MELBOURNE STAFF BEFORE TAKING YOUR FIRST CLASS/SESSION

FULL NAME:__________________________________________

Please circle the answers that apply to you.

1. Has your doctor ever said that you have a heart condition or vascular disease?*
YES            NO

2. Do you ever experience chest pains?*

YES            NO

3. Do you ever feel faint, dizzy, lose balance or lose consciousness?*

YES            NO

4. Has your doctor ever said you have high blood pressure (140/90)?*

YES            NO

5. Are you currently pregnant?*

YES            NO

6. Do you have a bone or joint problem that could be made worse by a change in your physical activity?*

YES            NO

7. Do you suffer from diabetes?*

YES            NO

8. Do you suffer from epilepsy?*

YES            NO

9. Have you been diagnosed with a mental illness that could be aggravated by Fitness or Martial Arts training?*

YES            NO

10. Do you know of any other reason why you should not participate in physical activity?*

YES            NO

If “Yes”, please specify: ____________________________________________________________

If “Yes”, please specify:____________________________________________________________

11. Have you answered YES to any of the above questions?*

YES            NO

12. Do you suffer from any allergies that could be aggravated by Fitness or Martial Arts training?*

YES            NO

13. Do you suffer from asthma or any other respiratory illness?*

YES            NO

*You agree to always have your Inhaler/Asthma Medication with you at FMC Melbourne. *You are accustomed to exercise and management of your Asthma.

DATE:_________________________________________________

SIGNATURE:___________________________________________