1. Have you been diagnosed with a heart condition? Or do you have an irregular heart beat?
2. Do you have chest pain or discomfort when you are physically active? Do you have this pain even when you are not exercising?
3. Do you have high or low blood pressure?
4. Do you ever become dizzy, lose your balance or lose consciousness?
5. During the past year, have you fallen over more than twice?
6. Do you have problems with your bones or joints? If so, does this problem become worse when you exercise?
Do you have any of the following? Please tick the appropriate box The personal information you have provided on this form will remain confidential, will not be dislosed to anyone outside of the CUFitter team and will be treated in accordance with the General Data Protection Regulation (GDPR).
Participant Information Consent
I hereby state that I have read, understood and answered honestly all the questions in the questionnaire and that any statements made by me in answering this Pre-Activity Questionnaire are true and accurate.
I realise that my participation in these activities could include the risk of injury and I understand that I am personally responsible for monitoring my own responses during exercise and will inform the fitness specialist immediately or any new or unusual symptoms, changes in my medication and results of any investigations or treatments.
I wish to participate in the CUFitter exercise programme supervised by a fitness specialist. I understand that my participation in the programme is entirely voluntary and that I am free to withdraw at any time.
Please tick the box if you agree to all of the above
Submit
Thanks for submitting! Our CUFitterXtra Fitness Specialist will be in touch shortly via email with your online class recommendation.
