Medical and lifestyle questionnaire

PRE-SCREENING

Name

Telephone Number

Email

Emergency Contact

Doctor

Address

DOB

Emergency number

Doctor Telephone Number

Occupation

Physical activity history 

In the last year how often have you participated in physical activity?

Is there anything in your medical history that could affect your capacity to exercise?

Medical history

Tick the box if you have experienced any of the following, past or present

If you have ticked any of the boxes please give further details

Are you on any medication? If so please give details

What (if any) has been your experience with running so far

I confirm that I declare myself  fit to run and I understand that participation in this group is entirely at my own risk. I have answered all of the questions correctly and all medical  and health considerations have been disclosed. Please note that it is your responsibility to inform your instructor of any medical condition that may affect your health whilst under their instruction 

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