Move Better, Think Better

Virtual classes

with

Louise Davidson

Thank you for showing interest in the 'Move Better, Think Better' virtual classes with Louise Davidson.

In order to gather more information about yourself, your health and issues that affect you, please complete the form below.  This will allow me to tailor the classes to fit with your specific needs and difficulties.

At the bottom of the form there are some statements and disclaimers.  Please read and tick the relevant box to show that you understand and agree.  

If you have any questions or would like further clarification, please Contact Me 

All information you provide will be confidential and only used for the purpose of developing these classes.

Thanks for your time.

Louise
 

 

 

ABOUT YOU
Please provide your full name
Please provide your email address
Please select your Gender
Female
Male
Please select which is applicable
Please enter your age
We are interested in what categories you are part of, please select all that applies:
Cognitive Impairment
Dementia
Other Neurological Conditions
Family Member/Carer
Please select all that apply to you


ABOUT YOUR HEALTH
Please provide details
Please provide date(s)
Please provide details
Please provide all medication


ABOUT YOUR MOBILITY
Does each side of your body feel equal in strength when standing?
Yes
No
Select which applies
How is your balance, does it change some days?
Yes
No
Please select
Feel free to add any more details here
Please provide details
Please provide details
Please provide details of your current exercise type


OTHER HEALTH CONDITIONS
Please provide details of your approximate water intake
Do you have any eye disturbances, please explain?
Yes
No
Please select
Please provide details
Have you had any past traumas?
Yes
No
Please select
Do you have any mental health issues?
Yes
No
Please select
Please provide details
Do you suffer from any seizures or fits?
Yes
No
Please select
Please provide details
Are there any other existing health conditions / concerns you are aware of that you would like to disclose?
Please provide details
This will be taken into consideration for class content to better support you, so you get the best out of each session.


DISCLAIMER
Please read the statements and tick the boxes to indicate you agree:

I understand that I have enrolled in a program of physical activity including but not limited to movement practices.
Please read statement and tick to agree

I understand that I am free to modify or abstain from any exercise in class and assume full responsibility for my physical health when following any 'Move Better, Think Better' virtual classes.
Please read statement and tick to agree

I understand and agree to the following disclaimer:
We strongly recommend that you consult with your physician when in doubt. The information provided is not intended to be a substitute for professional medical advice, diagnosis or treatment. Never disregard professional medical advice, or delay in seeking it.
Agreement to this Liability waiver will act as your continued agreement to all ensuing sessions, workshops and/or seminars whether in person, via Skype, Zoom or any other video conferencing tool.
Please read disclaimer and tick to state you agree and understand



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