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Health declaration

The purpose of this form is to make your teacher and RHSD aware of any health issues you may have, which may affect which exercises the teacher feels are suitable for you. In the rare case an accident does happen in class, we are also able to show this form to medical professionals. If any info you give in this form changes over time, please let your teacher know and complete a new form. Nothing you give will be sent to anyone else and will be kept in a secure location.

Date of birth
Do you suffer from chest pains, or any heart trouble?
No
Yes
Do you ever have spells of dizziness or feel faint?
No
Yes
Do you suffer from epilepsy?
No
Yes
Have you ever had either high or low blood pressure?
No
YES
Do you suffer from severe headaches or migraines?
No
YES
Are you recovering from a recent illness/operation or injury?
No
YES
If you suffer from any conditions, do you have your doctor’s approval to take exercise?
YES
NO
N/A

PLEASE NOTE: If you answered YES to any of questions, you are advised to seek medical advice/ approval before commencing an exercise class or consult further with your teacher.

I have been informed both verbally / in writing that if I answer YES to any of questions 1-12 of this questionnaire, I should seek medical advice/approval before taking part in exercise classes. If I wish to continue without such advice I do so entirely at my own risk.

I hereby state that I have read, understood and answered honestly the questions on the PAR-Q. If my medical status changes I will need to inform the teacher. I understand that RHSD and any of its employees cannot be held responsible for any injuries or ill health arising from my participation in the exercise classes. RHSD teachers are committed to delivering safe classes ensuring correct technique is taught and learnt, I so still realise that in participating in these activities I may be at risk of injury. I hereby confirm that I am participating voluntarily.

RHSD

Address: 6 North Isla Street, DD3 7JQ (studio 1&2) | Contact: pilates@rhsd.co.uk | www.rachelharrisschoolofdance.co.uk

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