Online Motion & Flow Dance Program - Class 2 - Arthritis & Osteoporosis Tasmania

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Class:*

Name*

First Last

Email*

Preferred phone number*

Age (in years)*

Please enter a number from 18 to 100.

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Date of Birth*

Type of arthritis

Would you like to sign-up to our eNews?*

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Week 1

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Week 2

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Week 3

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Week 4

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Week 5

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Week 6

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Week 8

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Week 7

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Week 9

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Week 10

Participant Policy

Medical Clearance

1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?*

Yes

When did this occur (Month, Year)? Has it been suitably diagnosed and/or resolved or is it requiring ongoing management?*

Date of Event (MM/YYYY)

Detailed summary of the event

Resolved or Ongoing

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As you answered Yes, please give more information on the nature of your condition and when it was first diagnosed

2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?*

Yes

As you answered Yes, has you answered Yes, has this occurred in the last 1-3months and are you aware of the (potential) cause or condition that may be attributed to this experience (e.g. diabetes, cardiorespiratory disorder or other)?*

3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?*

Yes

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*

Yes

As you answered Yes, do you require any medication to assist you during exercise (e.g. ventilator, reliever etc)

5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?*

Yes

As you answered Yes,*

Are you currently taking any medication that is designed to bring this into control? (Yes/No)

If so what medication are you taking?

Please click the + to list additional medication

6. Do you have any other CURRENT conditions that may require special consideration for you to exercise? (This many include previous or current injuries/conditions -e.g. recent/current fractures, cancer diagnosis/treatment, neurological conditions, etc)*

Yes

MoveDuplicate Settings Delete As you answered Yes, please provide a brief but detailed summary of your recognised special consideration (e.g. time of event, nature and whether it is resolved or ongoing*

Date of Event (MM/YYY)

Detailed summary of special consideration

Resolved or Ongoing

Please click the + to list additional medication

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As you answered Yes, please provide a brief but detailed summary of your recognised special consideration (e.g. time of event, nature and whether it is resolved or ongoing)

7. Please reflect on your health during the current periods, and note any health developments (e.g., injuries, condition diagnoses) that you think may be relevant to your participation in our exercise (Note: if no major/significant issues have arisen please write N/A)

Last 6 months:

Last 12 months:

Last 3 years:

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8. Please reflect on your health during the current periods, and note any health developments (e.g., injuries, condition diagnoses) that you think may be relevant to your participation in our exercise (Note: if no major/significant issues have arisen please write N/A)*

Yes

8. Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities. For intensity guidelines download the Exercise Intensity Guide.

Frequency (number of sessions per week)*

Light

Moderate

Vigorous/High

Duration (total minutes per week)*

Light

Moderate

Vigorous/High

Total minutes per week

Total minutes = (frequency x duration)

9. Have you had any falls in the past 12 months? If so, how many?

None

1 fall

2 falls

3 or more

10. When walking and turning, are you unsteady or at risk of losing your balance?

No unsteadiness observed

Yes, minimally unsteady

Yes, moderately unsteady (needs supervision)

Yes, consistently and severely unsteady (needs constant hands-on assistance)

11. Are you experiencing any CURRENT neurological concerns such as headache, dizziness, weakness, numbness, tingling, tremors, loss of balance, loss of memory or decreased coordination?

Yes

As you answered Yes,*

Is it currently affecting you in your day to day?

Has it been attributed to a previously diagnosed condition

Are you undergoing current investigations into why it is occurring?

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As you answered Yes, please provide more detail*

12. Have you been admitted to hospital for any acute complication within the last 6 weeks?*

Yes

As you answered Yes, please provide more detail*

Arthritis TAS Exercise Participation Waiver

READ CAREFULLY BEFORE SIGNING

In consideration for my participation in “The program” hosted by Arthritis TAS. I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND HOLD HARMLESS for any and all purposes SPONSOR, Arthritis TAS and their respective officers, servants, agents, volunteers, or employees (herein collectively referred to as RELEASEES) FROM ANY AND ALL LIABILITIES, RESPONSIBILITIES, CLAIMS, DEMANDS, CAUSES OF ACTION OR INJURY, INCLUDING DEATH, that I may sustain or to any property belonging to me whether caused by the negligence of the RELEASEES or otherwise, while participating in the Program, or while in, on or upon the premises where the Program is being conducted.

Consent Date*

Payment

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Billing Date*

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Days Counter*

Loosen Up

Price:

The price is pro-rata so if you join during the term, the price will be calculated automatically. Please note: If you register on the day of the class, you will join the class the following week.

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Credit voucher code:

Total

Credit Card*

This field is for validation purposes and should be left unchanged.

Online Motion & Flow Dance Program – Class 2

Registration: Motion & Flow 11am Tuesday

Participant Policy

Medical Clearance

Arthritis TAS Exercise Participation Waiver

Payment