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Health declaration

Please fill out the following form before you do your first class.

Date of birth
Day
Month
Year
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
No
Yes
Do you feel pain in your chest when you do physical activity?
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?
No
Yes
Do you lose your balance because of dizziness or do you ever lose consciousness?
No
Yes
Do you have a bone or joint problem (e.g., back, knee or hip) that could be made worse by a change in your physical activity?
No
Yes
Is your doctor currently prescribing any medication for your blood pressure or heart condition?
No
Yes
Are you pregnant or have you had a baby in the last 6 months?
No
Yes
Do you know of any reason that would affect your ability to participate in physical activity?
No
Yes
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