You will be asked to complete a health form prior to joining a session with Kate. Please either copy and paste the below and return to Kate on receipt of her Zoom class. Alternatively she will send to you the form to complete in advance of the session.
By booking a session, you confirm that you have disclosed all current investigations into your health and advised of any conditions that you may have, and consent to attending group and or individual sessions.
Please complete the below health form once you have booked your session with Kate.
Tai Chi For Health – Informed Consent Form
Name:
D.O.B.:
Address:
Phone:
Email:
Next of Kin and Contact:
Fit to Exercise: PAR-Q
Is your GP prescribing you any medication for your blood pressure or heart? Y/N
In the past month, have you had chest pain when you were NOT doing physical activity? Y/N
Has your GP ever said you have a heart condition and should not do physical activity? Y/N
Do you feel pain in your chest when you do physical activity? Y/N
Do you loose balance or experience dizziness? Y/N
Do you have bone or joint problem that you’ve been advised could be made worse by physical activity? Y/N
Do you know of any other reason why you should not do physical activity? Y/N
What do you hope to gain from attending Tai Chi?
Have you practiced Tai Chi Before?
What is the frequency of present exercise
Based on the risk assessment I have to make you aware that one is at greater risk if: You are an older male, have a high body mass index (BMI), have health conditions like diabetes, or if you are Black Asian or minority ethnicity (BAME) backgrounds.
I confirm that I have disclosed all current investigations into my health and advised of any conditions that I may have, and I consent to attending group and or individual sessions.
Signature: _____________________
Print Name: _____________________
