PilogaFit  Health Questionaire

Please complete this questionnaire before starting your first class

Confidential

Name (Please print) -

Town or Village -

PilogaFit class attending -   Wedmore Village Hall    Wednesday   10.30 - 11.30am

The objective of the PilogaFit class is to progressively increase your Core Stability and joint Dynamic Stability. This is to be achieved through low intensity and low impact exercise.

The following is to ensure your safety. If you have any concerns, please contact your GP before starting any exercise class or if you feel unwell during or after.

Has your doctor advised against low impact, low intensity exercise ?

Yes

No

Please indicate any health conditions your doctor is aware of

-

-

-

Please indicate any health conditions your doctor is not aware of

-

-

-

I understand my physical limitations and will practice safely at my own level.

If I feel ill or pain I will stop immediately. I will then contact my GP.

I will take full resposibility for my health during the class and after.

If necessary, I will ask for modifications of the exercises.

Signed                                                           Date