Dance-A-Thon Medical Questionnaire Name* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Last Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Emergency Contact Name*Emergency Contact Number*Have you ever suffered with epilespy? WARNING due to lighting this class is not suitable for you.*YESNOAre you pregnant, unfortunately due to the darkened room is is not advisable to start this program whilst pregnant.*YESNOHave you just had a baby?*YESNOHow long ago?*Have you been signed off by the midwife after 6 week check.*YESNOHave you ever suffered with heart problems?*YESNOPlease advise*Have you ever suffered with heart problemsAre you presently taking any form of medication?*YESNOPlease advise*Are you presently taking any form of medicationDo you suffer from chest pain?*YESNODo you ever have spells of dizziness or feel faint?*YESNOHave you ever high either high or low blood pressure?*YESNOPlease advise*Have you ever high either high or low blood pressureHave you ever had high cholesterol?*YESNOHave you ever had asthma, chronic bronchitis or any other chest aliments?*YESNODo you suffer from severe headaches or migraines?*YESNODo you suffer with severe back pain or any orthopedic problems?*YESNOPlease advise*Do you suffer with severe back pain or any orthopedic problemsIs there any history of heart disease in your immediate family (before the age of 55)*YESNOHave you any medical condition that we should be aware of?*YESNOPlease advise*Have you any medical condition that we should be aware ofPLEASE NOTE: IF YOU HAVE ANSWERED YES TO ANY QUESTIONS WE ADVISE YOU TO SEEK MEDICAL ADVISE/APPROVAL BEFORE TAKING PART IN THIS CLASS.Medical History Consent*I have been informed both verbally and in writing that if I answer YES to any of the above questions I should seek medical advice/approval before commencing in this class. If I wish to continue without such advice I do so entirely at my own risk. I confirm that I have read, fully understood and answered honestly. I understand that neither the Instructor or Clubbercise Ltd can be held responsible for any injuries or ill health of any kind arising from participation within this class. I AGREE TO THE ABOVEPhotos and Videos Consent*Please note small video clips/photos in darkened lighting maybe taken of class from time to time which maybe posted on social media pages IE Facebook/Instagram and other forms of media. I AGREE TO THE ABOVECAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.