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TAI CHI
What is Tai Chi?
History
Hsing I
CHI KUNG
What is Chi Kung?
Chi Kung forms
CLASSES
Classes overview
Online
Cambridge
Weekend classes
One to one
HOW TO JOIN
ADRIAN MURRAY
Teaching
Who is Adrian Murray?
My Masters
Contact
Physical Readiness Questionnaire
All students are required to complete this questionnaire so that we can communicate with you about classes you have signed up for and in order to comply with our insurance and health and safety requirements. If you are between the ages of 15 and 69, this questionnaire will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, please check with your doctor before commencing classes.
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Indicates required field
Name
*
First
Last
Date of birth (DD/MM/YY)
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Postal address
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Telephone
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Email
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Do study your chosen subject/s with another teacher?
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Yes
No
Do you teach Tai Chi / Chi Kung / Hsing I and/or intend to profit from these classes by teaching thereafter?
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I do teach
I do intend to teach
I do not teach
Do you have any conditions that might cause us to need to summon medical attention?
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Yes
No
If yes, please specify
*
Do you have injuries or physical conditions that need to be taken into consideration?
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Yes
No
If yes, please specify
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Please read each of the following questions carefully and answer honestly by indicating YES or NO.
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
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Yes
No
Do you feel pain in your chest when you do physical activity?
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Yes
No
In the past month, have you had a chest pain when you were not doing physical activity?
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Yes
No
Do you lose balance because of dizziness or do you ever lose consciousness?
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Yes
No
Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity?
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Yes
No
Is your doctor currently prescribing medication for your blood pressure or heart condition?
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Yes
No
Do you know of any other reason why you should not take part in physical activity?
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Yes
No
If you answered YES to one or more questions: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.
If you answered NO to ALL of the questions: It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.
Declaration
By entering the date and clicking submit below, I confirm that the information given is correct at the time of submission and that I will inform you if this information needs updating at any time. I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury. If I have answered yes to any of the questions, I understand that I cannot attend classes without having first sought medical advice and agreement from my GP that I may safely exercise.
Disclaimer
*
Yes I have read the disclaimer information
.
The disclaimer page can be accessed
here
. Please confirm by ticking the box above that you have visited and read this page.
Today's date
*
SIGNATURE - please note we require a signed copy of this form so please print and sign in the box before clicking submit, scan and email to us or bring to class.
*
I confirm I have printed and signed this document.
*
Printed (from browser file > print)
Signed (please email scan/photo or e-signed pdf to
[email protected]
)
Thank you for completing the questionnaire. Should your condition change this version of the questionnaire will become invalid and you will be required to resubmit it. Your information is held in compliance with 2018 GDPR legislation, you can see our policy
here
.
Submit
