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07939 183 173

info@kravmagawest.co.uk

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ACCIDENT FORM.

Name: Krav Maga West
Address: Dunkley Street, Wolverhampton, WV1 4AN, GB
Telephone: 07939183173
Price range: £10-£50

Health Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Address

Last Name

Date of Birth

Post Code

Phone

Emergency Contact

Has your doctor ever said you have heart trouble? *

Yes

Do you suffer with chest pains when exercising with mild exertion? *

Yes

Do you suffer with dizziness or fainting? *

Yes

Has a doctor ever said your blood pressure is too high? *

Yes

Has a doctor ever said you have a joint problem that maybe aggravated or made worse by physical exercise? *

Yes

Have you been in hospital in the last 3 years? *

Yes

Are you currently taking any medication? *

Yes

Do you have a medical condition/take any medication that may mean you bruise/bleed more easily? *

Yes

Do you suffer with asthma or breathing difficulties? *

Yes

Is there a possibility you may be pregnant or have recently given birth? *

Yes

Do you suffer with Diabetes or Epilepsy? *

Yes

Do you suffer from any allergies? *

Yes

Have you ever been convicted for any offence involving any kind of bodily harm? *

Yes

Is there any reason not mentioned here why you should NOT take part in a physical activity, which will involve contact and impact? *

Yes

If you answered yes to any question, please elaborate

DECLARATION: "I understand I am taking part in an activity that may cause injury, involve contact and is highly physical in nature. If i have answered 'Yes' to any of the above questions I will inform the instructor prior to commencing my trial or regular class. I have answered these questions honestly and to the best of my knowledge.

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