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Health Declaration Form

DOB
Day
Month
Year
Do you have a heart condition or high blood pressure?
Yes
No
Do you feel chest pain when you exercise or at rest?
Yes
No
Do you have dizziness or lose consciousness?
Yes
No
Do you have a bone, joint or muscle problems that could be made worse by exercise?
Yes
No
Are you taking medication for a medical condition?
Yes
No
Are you pregnant?
Yes
No
Do you know of any other reason you should not exercise?
Yes
No

I understand that I am about to participate in pole / burlesque fitness class and that it can be a hazardous and strenuous activity. I declare that I believe I am in good health and physical condition, I have informed my instructor of any ailments or health issues that I have, I am aware that undertaking physical activity of this nature can be a risk, I therefore participate at my own risk and take full responsibility for my actions. PB Dance & Fitness can’t be held responsible for any personal injury or accident. I have read the PB terms & conditions, understand them and agree to follow them.

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