PD PARQ SEND Form | Gill Dawson PT & Fitness Coach

PD PARQ SEND

Date

First name

Last name

Date of birth

Day

Month

Year

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Emergency contact name and number

Consent to be added to class Whats App group:

When were you diagnosed?

Who is your consultant / Parkinson's nurse?

What exercise do you currently engage in?

Are you able to move about without aids or assistance?

Can you get on and off the floor independently?

Have you had any falls? If so, how many in the last 3 months?

Do you experience any freezing episodes?

Do you experience on /off periods?

What activities do you have trouble with (if any)?

Do you work?

Do you drive?

*If answers are yes to any of these questions - a physio / OT assessment or 1:1 session may be recommended prior to attending class, to ensure safety and suitability.

MEDICAL HISTORY:

Do you have any other medical conditions that you see the doctor about?

Do you have a history of cardiac problems including high or low blood pressure?

Do you have a history of respiratory problems including breathlessness?

Do you have any other conditions that effect your ability to exercise?

Have you had a recent injury, pain, any surgery or illness?

Please Sign and Date to confirm this is information is correct at time of completing.

If any symptoms or your condition changes, please let Gill know.

Date

Day

Month

Year

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Any additional information.

PD PARQ SEND

Get in Touch