Please fill the form below before your first class.

Medical History

This information will be treated confidentially

* Name
* Date
Please answer yes or no to any of the following conditions you currently have or have had in the past
* Heart attack, heart disease, cardiac surgery	Please select Yes No
* Asthma or other respiratory ailments	Please select Yes No
* Migraines or recurrent headaches	Please select Yes No
* Neurological or muscular disorders e.g. Multiple Sclerosis	Please select Yes No
* Arthritis, Rheumatoid, Osteo or other
* Light-headedness or fainting	Please select Yes No
* Swollen, stiff or painful joints	Please select Yes No
* high blood pressure	Please select Yes No
* Low blood pressure	Please select Yes No
* Stroke	Please select Yes No
* Diabetes	Please select Yes No
* Hernia	Please select Yes No
* Epilepsy or seizure	Please select Yes No
* Accidents	Please select Yes No
* Bursitis	Please select Yes No
* Kidney disease	Please select Yes No
* Osteoporosis	Please select Yes No
* Anemia	Please select Yes No
* Fractures/dislocations	Please select Yes No
If you marked yes to any of these conditions, please write the details in the textbox below. Include details about any medications you are taking and if there are any side effects as these could influence your performance in class or the types of classes you should receive. information
Details
* Do you have any conditions, illness, disease or any other medical condition not outlined above, as this may affect either your performance in class or the type of class you should receive.	Please select Yes No
If yes, please explain
* Are you pregnant now or have you been in the last three months?	Please select Yes No
* Have you had surgery or been hospitalized in the last two years?	Please select Yes No
* Do you have an injury or problem area e.g. neck, shoulders, low back?	Please select Yes No
If yes, please explain