Warm Water Class Questionairre Please complete the registration form, including payment details below. "*" indicates required fields HiddenClass:*WWX - CSTHLL - 1.30pm WednesdaysWithdrewName* First Last Email* Preferred phone number*Date of Birth* Day Month Year Type of arthritisOsteoarthritisRheumatoid ArthritisPsoriatic ArthritisAnkylosing SpondylitisGoutOther Autoimmune Condition (e.g. Lupus)UndiagnosedNot KnownEmergency Contact*NamePhone Add RemoveWould you like to sign-up to our eNews?*YesNoAlready subscribedHiddenWeek 1 HiddenWeek 2 HiddenWeek 3 HiddenWeek 4 HiddenWeek 5 HiddenWeek 6 HiddenWeek 7 HiddenWeek 8 HiddenWeek 9 HiddenWeek 10 Participant PolicyConsent* I have read and agree to the Exercise Program Participant PolicyMedical Clearance1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?* Yes No 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 No As you answered Yes, are you aware of the (potential) cause or condition that may be attributed to this experience (e.g. Diabetes or cardiorespiratory disorder) 3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?* Yes No 4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?* Yes No 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 No 6. Do you have any other 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 No 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 No)Last 6 months: Last 12 months: Last 3 years: Hidden8. 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 No)* Yes No 9. 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)*LightModerateVigorous/HighDuration (total minutes per week)*LightModerateVigorous/HighTotal minutes per weekTotal minutes = (minutes of light + moderate) + (2 x minutes of vigorous/high)10. Do you have any open surgical/non-surgical wounds or current skin rashes?* Yes No As you entered yes, please provide more detail* 11. Can you transfer in and out of the pool?* Independently Assistance required Dependently As you entered Assistance required or dependent, please provide more detail* 12. Do you have any issues with incontinence?* Yes No As you entered Yes, please provide more detail* 13. Please rate your swimming strength* Poor Fair Good Excellent 14. Are you aware of any neurological issues that make it difficult for you to regulate your blood pressure in water?* Yes No As you entered Yes, please provide more detail* 15. Have you been admitted to hospital for any acute complication within the last 6 weeks?* Yes No As you entered Yes, please provide more detail* Arthritis NSW Exercise Participation WaiverREAD CAREFULLY BEFORE SIGNING In consideration for my participation in “The program” hosted by Arthritis NSW. I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND HOLD HARMLESS for any and all purposes SPONSOR, Arthritis NSW 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* I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct.Consent Date* DD slash MM slash YYYY HiddenSign up date* DD slash MM slash YYYY HiddenBilling Date* DD slash MM slash YYYY HiddenDays Counter*HiddenCredit voucher code: NameThis field is for validation purposes and should be left unchanged.
