Roberta Freeland, Your Home Health Club



Roberta Freeland - Fitness Instructor and Yoga Teacher
Name: ________________________________      Date of birth: _____________________
Email: ________________________________      Contact number: ___________________  


Do you suffer or have you suffered from any of the following conditions?     Y / N
1. Heart conditions/angina/chest pain/pacemaker fitted     
2. High blood pressure     
3. Low blood pressure     
4. Asthma     
5. Diabetes     
6. A stroke (if yes, please specify how long ago)
7. Epilepsy     
8. Joint pain, neck pain or back pain     
9. Have you had any operations or serious illness with the past 12 months?     
10 Are you taking any prescribed medications?     
11. Are you pregnant or have you given birth within the last 6 weeks?     
12. Do you suffer from any medical conditions that may be affected by exercise?     
*If you have answered YES to one or more questions, you are advised to check with your GP or a medical practitioner before starting any physical activity.  
Please outline details of any health conditions or injury you have and of any medication you currently  take  
I certify that I am 18 years or older and I have read, understood and accurately completed this questionnaire
I acknowledge that by participating in any physical activity, I do so at my own risk  
I attest I am physically fit to participate safely in the activity and that a qualified medical practitioner has not advised me otherwise  
I am not aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in physical activity. In the event that I become aware of any medical condition, injury or impairment that may be detrimental to my health if I continue physical activity, my Trainer will be immediately informed.  
Signature __________________     Date: ____ 
I give my consent to Roberta Freeland to hold my personal information on the understanding that it will be held confidentially and not to be shared with any other person or business without my consent, in accordance with the GDPR (General Data Protection Regulation)*
Signature __________________     Date: ____ 
*You can request for your personal information to be removed at anytime by emailing ​​ nd it will be deleted immediately. An email will also be sent to you as a confirmation to this effect

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