Медицинская справка для занятий спортом в студии
(The questionnaire is worded in a male language for convenience, but it is also intended for a female)
Part I: Medical Questionnaire
Please read the questions below thoroughly and answer any questions honestly by marking in the appropriate box.
1. Did your doctor tell you that you have heart disease?
2. If you have chest pain?
(please mark your answer in any of the options below)
(do not fill out if this is not relevant to you)
3. During the past year
(please mark your answer in any of the options below)
(A) Did you lose your balance due to dizziness?
(Including during vigorous exercise).
(B) Have you lost consciousness?
4.If a doctor diagnoses that you have been suffering from asthma, so for the past three months?
(do not fill out if this is not relevant to you)
(A) Do you need medication?
(B) Have you suffered from shortness of breath or wheezing?
5. One of your family members of first degree has passed away?
(Please mark your answer in each of the options below)
A) from heart disease?
(B) From sudden death at an early age? (Before age 55 if it is a man, and before age 65 if it is a woman)
6. Did your doctor tell you in the last 5 years to exercise only under supervision
Medical?
7. Do you suffer from a permanent (chronic) illness that is not mentioned in the above questions and may prevent or restrict you from exercising?
8. Pregnant women: Has this pregnancy or any previous pregnancy been defined as a risk pregnancy?
(do not fill out if this is not relevant to you)
Part II: Guidelines
1. If you marked "Yes" one of the questions in Part A of this form - in order to be accepted into the studio, you must bring a medical certificate from a physician stating that the doctor confirms that there is no risk to your health at a studio workout.
2. Studio will receive a trainee who has issued a medical certificate that has not passed 3 months from the date of issue.
3. In the event of a change in your medical condition, consult a physician regarding continued activity at the studio.
Part III: Statement
I, the undersigned, hereby declare that I have read and understood the entire medical questionnaire in Part I of this form and have completed it myself.
I declare that I have provided complete and correct information about my past and present medical conditions according to the questions I asked in the questionnaire.
I know that after two years of signing this health statement, I will have to make a new health statement.
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