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PLEASE COMPLETE & SUBMIT THE FOLLOWING FORM

Health Screening Questionnaire

The completion of this form is a sensible first step to take if you are planning to increase the amount of physical activity in your life. For most people, physical activity should not pose a problem or a hazard. The PAR-Q has been designed to identify the small number of people for whom physical activity might be inappropriate or for those who seek medical advice concerning the type of activity most suitable for them. Common sense is your best guide for answering these questions.
If you can answer YES to any of the following questions, then you are required to gain consent from your doctor before participating in any Move Dance Fitness classes.
COVID-19 Self Screening 
  • Please do not attend class, and notify me immediately, if you or a household member develop any of the following symptoms:-
a high temperature
a new, continuous cough
a loss of, or change to, their sense of smell or taste
  • Please do not attend class, and notify me immediately, if you are under an isolation or quarantine order/directive.
  • Please respect the safety and hygiene standards and processes posted in venues and shared by class participants.
  • Please sanitise/wash hands prior to beginning a class.
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by the doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in physical activity?
Is you doctor currently prescribing drugs (for example, water pills) for blood pressure or heart conditions?
Do you know of any other reason why you should not do physical activity?
Have you been in close contact with a confirmed case of COVID-19 or have you yourself tested positive with COVID-19
If needed, do you consent to Melanie Wittmaack administering you with first aid treatment wearing PPE equipment
I would like to be added to the Move Dance Fitness newsletter . You will only be contacted with information relating to Move Dance Fitness classes, events and upcoming news. Your details will not be shared with any third parties.
Please note that no liability is accepted for any loss of or damage to any articles which you may bring with you to classes. Equally, liability is not accepted for loss or damage to motor vehicles or their contents and these are left at the owner's risk.

Your Signature

Phone: 07730 455856 | e-mail: mel@movedancefitness.co.uk

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