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:___________________________________________