NEW STUDENT QUESTIONNAIRE Form (#4)QUESTIONNAIR & REGISTRATION FORM FOR FITNESS CLASSESPlease complete the following questionnaire. The information I receive will allow me to plan the fitness programme (class) more effectively to suit your own needs and interests. Any information you provide will be kept confidential and will be not be disclosed to any individual or organization.Name : Mr./Ms/Mrs.AgeHeightWeight (kg.)Contact Details:- Address Line 1Address Line 2CityStateMobile No.CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweZip CodeEmailEmergency ContactContact No.NameHave you ever done any kind of workout? - Select -YesNoIf yes, please provide further details (eg: style & for how long)What is your main reason to start your workout with us? To increase Stamina To increase muscle strength Flexibility Pain Relief Relaxation Stress Relief Meditation Weight Loss Cure specific medical condition OtherYOUR HEALTH: The following information is required to ensure your safety. Whilst workout may be practiced by the majority of people, there are certain conditions which require special attention. The following conditions require specific modifications to your fitness practice. Please tick if any of the following to apply to you. If you tick, please provide further details below: Abdominal disorders Arthritis (osteo/rheumatoid) Back pain/problems Heart Conditions/ Disorders High Blood Pressure Hip Problem Low Blood Pressure/ Fainting Knee Problem Nerve Damage/Trauma Osteoporosis Pain, Stiffness, Swelling Pregnancy/recent pregnancy Broken Bones Surgery (in the last two years) Shoulder/Neck Problems Thyroid Anxiety/stress/depression * Auto-immune disorders Anxiety/stress/depression Balance affecting disorder (eg Diabetes Epilepsy Respiratory problems (e.g. asthma) Sensory disorders affecting eyes/ears OtherDo you have any other medical conditions not covered above that might be adversely affected by fitness practice or are likely to cause your concern? * I have read and agree to the Terms and Conditions and Privacy Policy I take full responsibility for my health during fitness program. I understand that it is my responsibility to: Share with the instructor of any change in my medical information or other, which may be relevant before the start of each class. Follow the advice given by instructor. Take full responsibility for not exceeding my physical limitations and for any injury that might occur as a result. Only do what feels comfortable in class and to work in pain. To inform the instructor if I experience any difficulty in class To practice mindfully and safely. Submit Form