Medial Form - Middleton Lodge

Medical Form

Welcome to Sunrise Yoga at the Forest Spa, we hope you will enjoy your session.

For us to maintain your safety we need to be aware of any existing medical conditions you may have and require that all guests fill out this form before attendance. This information is held strictly confidentially under the Data Protection Act (1998).

We also ask that our guests help us maintain the contemplative nature of the Forest Spa.

How did you hear about us?

Are you a resident with us here at Middleton Lodge Estate?

Do you have any medical conditions?

Are you a carrier of any infectious conditions?

Do you suffer from any known allergies?

Are you pregnant or do you believe you might be?

Have you ever been diagnosed with a high-risk condition during pregnancy?

Do you have any bone/joint problems such as arthritis, that could be aggravated by physical exercise?

Have you been diagnosed with any of the following: High Blood Pressure Low Blood Pressure Diabetes Metabolic Disease Raised Cholesterol Heart Condition

Is there a history of Coronary Heart Disesase in your family?

Have you felt pain in your chest when performing physical exercise?

Have you felt pain in your chest when NOT performing physical exercise in the last month?

Do you frequently feel faint, lose balance or have you lost consciousness?

Do you have a heart condition that requires exercise be signed off by a doctor?

Have you had any recent surgery

Is there any other reason why you should not participate in physical activity?

I hereby state that I have read and understood the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance exercise and stretching. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me.

I accept

I agree to be added to Middleton Lodge's Mailing List

I agree

Always consult your doctor first about any concerns you may have about your health and seek your doctors advice on

your suitability for physical activity.. In certain cases, written permission will be required either by your GP/Specialist or a

Personal Disclaimer.

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Rebecca Hope
Cecelina Tornberg
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Rebecca Fraser
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Benjmain Wheeler

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