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Health Declaration

Please fill out the following form
in order to participate in our activity.

The Screening Tool below is intended for general use only and in no way guarantees against harm to health
injury or death. Dance Fit Studio accepts no liability for any loss, damage or injury that may arise from any
person acting on any information contained in this tool.

1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
8. Are you pregnant or have you given birth within the last 12 months?
9. Do you know of any other reason why you should not participate in physical activity? If so please list below

IF YOU ANSWERED ‘YES’ to any of the above questions, please seek guidance from your GP or
appropriate allied health professional and return with a copy of the doctor’s clearance letter prior to starting

Thanks for submitting!

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