Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you participate in regular physical activity? *

Yes

No

Have you ever been diagnosed with a heart condition and recommended ONLY medically supervised activity? *

Yes

No

Do you experience chest pain brought on by physical activity? *

Yes

No

In the past month, have you experienced chest pain when you are not participating in physical activity? *

Yes

No

Do you lose balance, lose consciousness, or fall over as a result of dizziness? *

Yes

No

Have you had any falls within the last 6 months? *

Yes

No

Has a doctor ever recommended medication for your blood pressure or a heart condition? *

Yes

No

Have you ever been diagnosed with a seizure disorder? *

Yes

No

Do you have bone or joint problems that could be aggravated by a change in your physical activity? *

Yes

No

Have you been diagnosed with Osteopenia or Osteoporosis? *

Yes

No

Do you have problems with eyesight? *

Yes

No

Do you have any problems with hearing or wear a hearing aid? *

Yes

No

Have you had any recent pain, any surgery or illness? *

Yes

No

Do you know of any other reason why you should not take part in exercise, or do you have any condition that you would like to discuss with your instructor *

Yes

No

Are you taking medication for the following conditions? *

High blood pressure

Cardiac condition

Blood thinners (anticoagulants)

Respiratory problems

Diabetes

Epilepsey / seizures

Any neurological conditions

Infectious conditions

Any form of arthritis

Any form of pain

None of the above

Do you live alone? *

Yes

No

Are you working? *

Yes

No

Are you managing every day domestic chores? *

Yes

No

Are you managing daily personal activities like washing and dressing? *

Yes

No

Do you use walking aids? *

Yes

No

What transportation do you use? *

Drive

Public Transport

Taxi

Passenger

Other

Do you have additional help at home? eg carers *

Yes

No

What other activities / hobbies do you enjoy? *

Yes

No

Main motor symptoms *

Slowness

Tremor

Freezing

Balance DBS

Voice

Post

Dyskinesia

Dystonia

Other

Main non motor symptoms *

Memory

Anxiety

Mood

Sleep

Fatigue

Bladder

Bowel

Cramps

Other

Do you currently have any symptoms of Coronavirus (however mild)? For symptoms see the NHS website *

Yes

No

Has any member of your household or somebody you have been in close contact with displayed any symptoms of coronavirus or been tested positive for the disease within the past 14 days. It is strongly recommended that clients are using the NHS contact tracing app to minimise the risk of spreading the Coronavirus disease. *

Yes

No

Have you been notified by the NHS contact tracing app that you should be self-isolating for 14 days? *

Yes

No

Your Exercise Professional may implement specific Coronavirus safety measures such as: 2m personal separation; the wearing of face masks. Do your have any concerns about adhering to rules set by your instructor? *

Yes

No