Livewell | Harvest Health Questionnaire

Harvest Event*

General Client Details

Name*

Date of Birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Number*

Email*

GP Name and Address*

Where did you hear about LiveWell? Have you attended any other LiveWell service in the past?*

Medical Questionnaire

Are you currently experiencing OR ever been diagnosed with any of the following conditions?

*

Lower back pain
Pelvic pain
Any other spinal condition
Any other oprthopaedic conditions
High or low blood pressure
Epilepsy (Grand mal seizures)
Heart problems
Osteoporosis/Osteopenia
NONE OF THE ABOVE

If you answered yes to any of the above, please provide details of the condition*

Are you pregnant?*

Please note that the only Harvest EXERCISE class we have scheduled that is suitable for a participant who is pregnant is the Mum-to-be Physio Fitness & Pilates Class. This is to ensure the safety of the participant. Please note that for the Mum-to-be Physio Fitness & Pilates Class, a pregnant participant must be greater than 12 weeks gestation and have medical clearance to exercise. Contact LiveWell at info@livewellwaterford.ie should you have any queries.

Have you ever had an episode of Lower back pain?*

If yes, how many previous episodes of Lower back pain have you had?*

Have you had any recent injuries or surgery?*

If yes, please provide details:*

Which, if any, of the following conditions have you been diagnosed with or had treatment for:*

If you have checked any of the above conditions, please explain/provide further information*

If you have other health conditions you would like to make known to us, please state them here:

What motivated you to book a space in this class?

Please take a moment to tell us about any expectations or hopes you have regarding the class. Is there anything you hope we cover with you in the class. Are you looking for help regarding an aspect of your health?

Have you done Pilates or Yoga before?*

If yes, please tell us about your experience of Pilates/Yoga*

If you haven't done pilates or yoga before, please tell us about other exercise you have been involved in.

What aspects of your health would you like to concentrate on?*

Core Stability
Flexibility
Posture
Pelvic Floor training
Toning
Relaxation
Other

If you answered 'other' to the question above, please explain/outline.*

Harvest Participation Informed Consent

This Harvest class will begin at a low level and will be advanced/modified within the class depending on your fitness level and ability. We may stop the exercise session because of signs of fatigue or excessive strain. It is important for you to realise that you may stop when you wish because of feelings of fatigue or any other discomfort.

There exists the possibility of certain dangers when exercising; abnormal blood pressure, fainting, irregular, fast or slow heart rhythm, and in rare instances, heart attack, stroke or death. Whilst every care will be taken, it is impossible to predict the body’s exact response to exercise. Every effort will be made to minimise these risks by evaluation of the preliminary information you provide in this form and by observations during exercise.

I understand that the Harvest Exercise Classes are specifically designed by the class instructor and will take into account details given in my health questionnaire. Therefore, this exercise should only be undertaken in a class setting, or when I have been given specific instructions to exercise on my own.

Please note that for publicity purposes, LiveWell Waterford may wish to take photos/videos during the scheduled events of the Harvest 'LiveWell' Day. This includes in the class setting. These photos/videos will be used for media purposes or on the LiveWell Website, publications and/or social media associated with LiveWell Waterford.

THIS INFORMATION IS PROTECTED BY THE DATA PROTECTION ACT 1984.

I have read and agree to terms*

Live Well Waterford

Harvest Health Questionnaire

Harvest Health Questionnaire

General Client Details

Medical Questionnaire

What motivated you to book a space in this class?

Harvest Participation Informed Consent

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