Libby Dixon – Exercise, Pilates, and Personal TrainingName*Telephone*Email* Emergency contact person*Phone*Why are you attending? What do you hope to achieve?Please tick any of the following that apply to you and give details below* Arthritis Back problems Breathing difficulties Diabetes Epilepsy Pregnant/post natal Sight problems Hearing difficulties Angina Stroke High or low blood pressure Heart surgery Heart problems Headaches/dizziness Hiatus hernia Varicose veins Osteoporosis Allergies Recent surgery Recent injury Other please detail below None of the above Details of any medical conditionPlease list any medication that you are currently taking*Is there anything else you think I need to know?Do you agree to me using photographs/images of you on social media?* yes no Consent* I agree to the privacy policy.*I understand that I am responsible for monitoring my own responses during exercise and will inform the tutor of any new or unusual symptoms. I will also inform the tutor of any changes in my medication, injuries etcSignature*
