Boost Buggy Workout

Booking Form and Questionnaire

Please enter your contact details below along with answers to questionnaire. I will get back to you immediately. Thank you for your interest.

Please detail any muscular, bone or joint injury from which you experience pain or restricted movement:
Injuries:
Please detail any previous operations, major illnesses or health condition which may affect your ability to undertake exercise:
Health condition:
Please list any medication you are currently taking or have taken in the last 6 months:
List medication:
Do you ever get short of breath with very light exertion?	Yes No
Do you ever experience pain, tightness or palpitations in the chest?	Yes No
Do you suffer from dizzy spells or fainting?	Yes No
Is there a family history of heart problems prior to the age of 60?	Yes No
Baby’s Name:
Date of Birth :
What type of birth did you have?	Natural Caesarian Section Other - Please state
Have you attended a post natal check up?	Yes No Other - Please state
Did you exercise during your pregnancy?	Yes No
If so, which type of exercise did you take?
Do you have any other children?	Yes No
If yes, how many?	0 1 2 3 4 5 6 7 8
I declare to the best of my knowledge, I know of no reason why I should not participate in Boost Buggy Workouts. I take part entirely at my own risk, and waive any legal recourse for any damage to myself, my children or my property, arising from my participation. If any of the above conditions change, I will inform the instructor before taking part in the Workout.
Please type in your initials to indicate that you understand above statement:
Enter Security Code:

Tel: 020 8546 4430
Mobile: 07944 714893

My e-mail address:info@davidboost.com