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MEDICIAL SCREENING

This information will remain confidential to KBPT, will be stored securely and will not be shared with any third parties other than in a medical emergency.

Your details

Name(Required)
Address(Required)
Have you suffered or are you suffering from any of the following? (please tick all that apply)(Required)
Has anyone in your family under the age of 60 suffered from heart disease or raised cholesterol?(Required)
Are you taking any prescribed medication?(Required)
Do you have any pain or injury, particularly in the region of the neck, back, knees or ankle?(Required)
Have you had any operation during the past 12 months? Have you ever had joint replacement?(Required)
Are you pregnant?(Required)
Do you smoke?(Required)
Is there any other aspect of your health not mentioned above that may affect the prescription of an exercise program?(Required)

Declaration

I, the undersigned, have read, understood, and answered the above questions fully and truthfully. I am aware of my responsibilities to consult with my G.P. regarding my medical fitness to engage in exercise. I do hereby intend to be legally bound for myself and waive release of any and all rights and claims for damages I may have against the exercise professional administering the exercise program provided to me.

Signed(Required)
DD slash MM slash YYYY
By signing this declaration you agree to our terms & conditions >
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LOCATIONS

Bethnal Green

Cambridge Heath

Clapton

Dalston

Forest Gate

Hackney

Hackney Central

Hackney Wick

Haggerston

Homerton

Hoxton

Leyton

Leytonstone

London Fields

Mile End

Shoreditch

Stepney

Stoke Newington

Stratford

Victoria Park

Walthamstow

SPECIALISMS

Weight Loss Training

Strength Training

Pre Natal Training

Post Natal Training

Rehabilitation Training

Running Training

Cancer Recovery Training

Training During Menopause

Training In Later Life

Bride To Be Training

Training To Ease Back Pain

Training To Boost Your Mental Health

Training For Lifestyle Change

Boxing Training

Nutritional Advice

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