WHITE DOG STUDIO - NEW MEMBER DISCLAIMER

Name *
Name
Address
Address
Gender
Date of birth
Date of birth
How did you hear about us? *
SECTION 1: KNOWN ILLNESSES OR CONDITIONS (TICK ANY THAT APPLY)
Do you have any of the following illnesses or conditions?
Have you ever had a stroke? *
Are you pregnant? *
Not a risk factor.
SECTION 2: SIGNS AND SYMPTOMS OF CARDIAC OR PULMONARY ILLNESS (TICK ANY THAT APPLY)
YES TO ANY EXCEPT PREGNANCY = HIGH RISK
Do you ever have pains in your heart and chest especially during exercise?
In the last 12 months have you ever felt an abnormal shortness of breath during exercise?
Do you ever feel faint or have spells of dizziness during exercise?
Do you often experience significant fatigue when you are not doing anything strenuous?
SECTION 3: RISK FACTORS (TICK ANY THAT APPLY)
Are you a male 45 or older?
Are you a female 55 or older?
Do you have a direct relative (parent, sibling, child) who had a heart attack or stroke at 55 or younger (males) OR 65 or younger (females)?
Has your doctor ever told you that you have high blood pressure?
Has your doctor ever told you that you have high LDL or total cholesterol?
Has your doctor ever told you that you have elevated fasting blood glucose levels?
Do you do less than 30 minutes of moderate intensity physical activity (e.g. brisk walking) most days (i.e. less than 150 minutes/week total)?
Are you a smoker, or have you quit within the last 6 months, or are you exposed to environmental smoke?
Conditions controlled by medication are still a risk factor (e.g. cholesterol lowering medication = risk factor for high cholesterol)
Has your doctor ever told you that your HDL cholesterol is high?
SECTION 4: CONTRAINDICATIONS TO EXERCISE
Have you been hospitalised or had a serious traumatic injury (e.g. motor vehicle accident) within the last 6 weeks?
Do you have any infectious diseases?
Do you now or have you recently had serious (6/10 or greater) pain caused by any of the following conditions and aggravated by exercise or particular movements:
Information Release and Informed Consent * *
I agree to my health information being shared with other health professionals for the purpose of improving my care (your information will never be shared for any non-medical purpose). Ask a staff member to guide you to the most suitable classes. On your first few visits, concentrate on learning proper technique and limit yourself to an intensity where you can still talk comfortably. Over time you can gradually increase your intensity level if you wish. Should you suffer any injury, illness, or condition in the future, please notify us by completing this questionnaire again. It is recommended that all males over 45 and females over 55 have a medical assessment including an exercise ECG, blood pressure, fasting glucose and cholesterol/lipid count. I acknowledge that the activity I am to undertake is at times dangerous and strenuous activity and that by participating in it I am exposed to certain risks. I acknowledge and understand that whilst participating in such an activity: I may be injured, physically or mentally, or may die, and that my personal property may be lost or damaged; other persons participating in such activity may cause me injury or death, or may damage my property; I may cause injury or death to other persons,or damage their property. I agree to enter and use all the facilities of TWD Pilates (White Dog Studio) entirely at my own risk. I recognise that the instructor offers only a guideline as to the limitations of my ability.