Livewell | LiveWell Dance PARQ

Class*

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*

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?*

If pregnant, written confirmation from GP, midwife or consultant is required before entry to the class.

Physical Activity Readiness Questionnaire

In order to participate in a LiveWEll exercise class, it is essential that you complete the following questions. Should you answer YES to any of the questions, you should attend your GP for a medical screen regards your suitability and safety for exercise. Once you have visited GP, you will be asked to sign your health form before starting the class, to acknowledge and agree that you have been given clearance to exercise.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*

Do you feel pain in your chest when you do physical activity?*

In the past month, have you had chest pain when you were not doing physical activity?*

Do you lose your balance because of dizziness or do you ever lose consciousness?*

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?*

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*

Do you know of any other reason why you should not do physical activity?*

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 classes. Are you looking for help regarding an aspect of your health?

Have you done Pilates or Dance before?*

If yes, please tell us about your experience.*

If you haven't done pilates, yoga or dance 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.*

Service Updates*

LiveWell likes to offer previous attendees to classes preferential booking notice and offers as well as keeping everyone up to date. To do this, LiveWell uses email to update current and past clients. Please check the relevant box below regards the LiveWell email list.

Participation Informed Consent

This 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 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 this is a Pop up trial class for a new service. For publicity purposes, LiveWell Waterford may wish to take photos during the class. LiveWell are sensitive to client's comfort and always attempt to take photos that do not show the identity of a participant. If a photo does, then you will be asked specifically for your permission to use it. These photos will be used for media purposes by LiveWell Waterford and 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

LiveWell Dance PARQ

LiveWell Dance Class PARQ

General Client Details

Medical Questionnaire

Physical Activity Readiness Questionnaire

What motivated you to book a space in this class?

Participation Informed Consent

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