SCHOOL Energize Day User
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Do you have any joint or bone problems that exercise may aggravate? Do you have high blood pressure? Do you have low blood pressure? Do you have Diabetes Mellitus or any other metabolic disease? Have you been told your cholesterol is raised (serum level above 6.2mmol/L)? Do you have any heart conditions? Have you ever felt pain in the chest area when you do physical exercise? Are you on any medication? Have you ever suffered from unusual shortness of breath from mild exertion? Is there any history of Coronary Heart Disease in your family? Do you often feel feint, have spells of dizziness or have lost consciousness? Do you smoke? Are you, or is there any possibility you may be pregnant? Do you know of any other reason why you should not participate in physical activity? YES
If yes, please give details: .................................................................................................................................................................. If you answered YES to one or more questions: If you have not already done so, consult with your doctor before increasing your physical activity. Tell your doctor which questions you answered YES to and seek advice as to your suitability for: 1. Unrestricted physical activity starting off easily and progressing gradually, and 2. Restricted or supervised activity to meet your specific needs, at least on an initial basis I herby state that I have read, understood and answered honestly the questions above. PARENT Name........................................................ PARENT Signature.............................................................
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NO